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CONCUSSIONS IN YOUTH SPORTS: EVALUATING 

PREVENTION AND RESEARCH 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

MAY 13, 2016 

Serial No. 114–145 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

DAVID B. MCKINLEY, West Virginia 

Vice Chairman 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

H. MORGAN GRIFFITH, Virginia 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

JANICE D. SCHAKOWSKY, Illinois 

KATHY CASTOR, Florida 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

JOSEPH P. KENNEDY, III, Massachusetts 

GENE GREEN, Texas 

PETER WELCH, Vermont 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 4 

Hon. Richard Hudson, a Representative in Congress from the State of North 

Carolina, opening statement ............................................................................... 6 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 7 

Prepared statement .......................................................................................... 9 

Hon. Fred Upton, a Representative in Congress from the State of Fred Upton, 

prepared statement .............................................................................................. 161 

WITNESSES

Kelli Jantz, Mother of Jake Snakenberg and Concussion Awareness Advocate 10 

Prepared statement .......................................................................................... 13 

Karen Kinzle Zegel, Mother of Patrick Risha and Chronic Traumatic 

Encephalopathy (CTE) Awareness Advocate ..................................................... 18 

Prepared statement .......................................................................................... 20 

Eugene F. (Buddy) Teevens, III, Head Football Coach, Dartmouth College ...... 29 

Prepared statement .......................................................................................... 32 

Andrew Gregory, M.D., Medical Advisory Committee Member, USA Football, 

and Associate Professor of Orthopedics, Neurosurgery and Pediatrics, Vanderbilt University Medical Center ...................................................................... 35 

Prepared statement .......................................................................................... 37 

Additional information submitted for the record ........................................... 51 

Kevin Margarucci, Manager, Player Safety, USA Hockey ................................... 61 

Prepared statement .......................................................................................... 63 

Steve Stenersen, CEO, US Lacrosse ...................................................................... 76 

Prepared statement .......................................................................................... 78 

Terry O’Neil, Founder/CEO, Practice Like Pros ................................................... 89 

Prepared statement .......................................................................................... 91 

R. Dawn Comstock, Ph.D., Associate Professor, Department of Epidemiology, 

Colorado School of Public Health ........................................................................ 102 

Prepared statement .......................................................................................... 104 

Thomas M. Talavage, Ph.D., Professor of Electrical and Computer Engineering, Weldon School of Biomedical Engineering, Purdue University ................ 122 

Prepared statement .......................................................................................... 124 

SUBMITTED MATERIAL

Subcommittee memorandum .................................................................................. 162 

Brochure, ‘‘REAP The Benefits of Good Concussion Management,’’ Rocky 

Mountain Hospital for Children at Presbyterian/St. Luke’s, submitted by 

Ms. DeGette .......................................................................................................... 169 

Brochure, ‘‘Flag Until 14,’’ Patrick Risha CTE Awareness Foundation, submitted by Ms. DeGette ......................................................................................... 189 

Report, ‘‘Sports-Related Concussions in Youth: Improving the Science, Changing the Culture,’’ Institute of Medicine and National Research Council 

of the National Academies, 1 submitted by Mr. Hudson 

1The information has been retained in committee files and also is available 

at http://docs.house.gov/meetings/IF/IF02/20160513/104914/HHRG-114- 

IF02-20160513-SD099.pdf. 

(1) 

CONCUSSIONS IN YOUTH SPORTS: 

EVALUATING PREVENTION AND RESEARCH 

FRIDAY, MAY 13, 2016 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 9:33 a.m., in room 

2123, Rayburn House Office Building, Hon. Tim Murphy (chairman 

of the subcommittee) presiding. 

Members present: Representatives Murphy, McKinley, Burgess, 

Griffith, Bucshon, Hudson, Collins, Cramer, DeGette, Schakowsky, 

Castor, Tonko, Yarmuth, Clarke, Green, Welch, and Pallone (ex 

officio). 

Staff present: Leighton Brown, Deputy Press Secretary; Rebecca 

Card, Assistant Press Secretary; Jay Gulshen, Staff Assistant; 

Kelsey Guyselman, Counsel, Communications and Technology; 

Brittany Havens, Legislative Associate, Oversight; Charles 

Ingebretson, Chief Counsel, Oversight and Investigations; John 

Ohly, Professional Staff Member, Oversight and Investigations; 

Chris Santini, Policy Coordinator, Oversight and Investigations; 

Gregory Watson, Legislative Clerk; Jeff Carroll, Democratic Staff 

Director; Ryan Gottschall, Democratic GAO Detailee; Tiffany 

Guarascio, Democratic Deputy Staff Director and Chief Health Advisor; Christopher Knauer, Democratic Oversight Staff Director; 

Ukna Lee, Democratic Chief Oversight Counsel; Elizabeth Letter, 

Democratic Professional Staff Member; Matt Schumacher, Democratic Press Assistant; and Andrew Souvall, Democratic Director of 

Communications, Outreach, and Member Services. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY. Good morning, and welcome to the Oversight and 

Investigations hearing. We are here today to continue the committee’s ongoing examination of concussions. This hearing follows an 

initial roundtable we had in March where we had a constructive 

dialogue with leading experts in the field about how to address the 

challenge of concussions. 

Today’s hearing will focus on youth sports, specifically the areas 

of prevention and research. 

While there’s always some risk of injury participating in sports, 

particularly at a young age, it is shown to have many benefits. The 

benefit of youth sports participation include better health through 

2 

increased activity, improved academic achievement, physical skill 

building and social development, to name a few. 

I might add that the number one health risk of youth is increasing rate epidemic proportion of child obesity. We know that that 

leads to increased adult risk for diabetes, cardiovascular disease, 

and all sorts of other problems. So we want children to pay careful 

attention to their nutrition and be active. 

While the estimates suggest that more than 30 million children, 

ages 5 to 18, participate in organized sports each year, and that despite this being the largest population of athletes, this group is one 

of the most underserved populations when it comes to the level of 

awareness, prevention, and research related to head injuries, which 

brings us to our task for today. 

We want to examine what is being done today to reduce the instance of head injuries to young athletes, what policies and guidelines are currently in place to limit their risk of injury? How are 

these policies developed? And do they go far enough, what educational and training policies exist for athletes, coaches, and parents? How does the large number of disparate leagues, teams, 

clubs, and recreational opportunities available to young athletes 

complicate efforts to improve injury prevention? 

While youth sports are not nearly as far along as many professional leagues, progress has made in recent years. All 50 States 

and the District of Columbia have enacted concussion laws and 

some youth sports, organizations, and leagues, such as Pop Warner 

Football, USA Hockey, U.S. Soccer, to name a few, have implemented policies to reduce the amount of head contact in practice 

and games. Others, such as USA Football, provide education and 

guidance to enhance training and awareness for coaches, parents, 

and athletes. A number of these groups are represented here today, 

and I look forward to hearing how their efforts are affecting their 

sports. 

Based on their experience thus far, are we doing enough, and 

what does the science tell us? The last question is particularly interesting and important. There’s a lot we do not know about concussions generally, but pediatric populations, including youth 

sports, are severely underrepresented in assisting research, and 

therein lays the challenge. 

The public wants answers that science is not ready to provide. 

We have much to learn how concussions and repetitive head injuries affect younger individuals, both immediately as well as later 

in life. Therefore, I’m interested to learn how youth sports, organizations develop, review, and update their policies, guidance or educational efforts in light of the limited but rapidly evolving research 

about concussions. 

We don’t know how traumatic brain injury affects our youth, and 

it makes that much more challenging to protect them. Adding to 

the challenge, we currently lack any form of protective injury surveillance, including concussions for athletes younger than high 

school age. Given the large number of athletes, teams, leagues, and 

other recreational opportunities, this is a daunting task. But if we 

do not understand the magnitude of the challenge, how different 

factors such as age, gender, sports, socioeconomic status, et cetera, 

3 

influence outcomes, how can we be sure we are making the best decision for our kids? 

This morning on our first panel, we are joined by two mothers; 

Ms. Kelly Jantz and Ms. Karen Zegal, both of whom tragically lost 

their son as a result of injuries sustained while playing youth 

sports. Ms. Jantz’ son, Jake, was a promising freshman athlete at 

Grandview High School in Aurora, Colorado, and is the namesake 

of Colorado’s Jake Snakenberg Youth Concussion Act. While Ms. 

Zegel’s son, Patrick Risha, was a star running back at Elizabeth 

Forward High School in my district and played football from the 

moment he could pick up a ball. We greatly appreciate your willingness to share your stories as it reminds us why it is so vital that 

we continue to examine this issue. 

Later on our second panel, we will have Dartmouth’s head football coach, Buddy Teevens, and representatives from some of the 

sports organizations, USA Football, USA Hockey, and U.S. Lacrosse that oversee or provide guidance to U.S. sports leagues. We 

will also hear from practice life pros to learn more about additional 

options to keeping athletes safe. 

Additionally, we have prominent researchers in the field. They 

will be able to speak to how we can approve research and surveillance, better monitor injuries, and minimize the risk of injury 

based upon science. 

I appreciate all of our panels for joining us this morning. This 

is an important issue, and your perspectives are important to advance the public dialogue on these complex injuries. 

I also want to thank Ranking Member DeGette for her support 

in this initiative and look forward to continuing our efforts together 

in this endeavor. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

We are here today to continue the committee’s ongoing examination of concussions. This hearing follows an initial roundtable that we had in March, where we 

had a constructive dialogue with leading experts in the field about how to address 

the challenge of concussions. Today’s hearing will focus on youth sports, specifically 

areas of prevention and research. 

While there is always some risk of injury, participating in sports, particularly at 

a young age, has shown to have many benefits. The benefits of youth sports participation include better health through increased activity, improved academic achievement, physical skill-building, and social development, to name a few. 

Estimates suggest that more than 30 million children, ages 5 to 18, participate 

in organized sports each year. Despite this being the largest population of athletes, 

this group is one of the most underserved populations when it comes to the level 

of awareness, prevention and research related to head injuries. 

This brings us to our task for today. We want to examine what is being done 

today to reduce the incidence of head injuries in young athletes. What policies and 

guidelines are currently in place to limit the risk of injury? How are these policies 

developed and do they go far enough? What educational and training policies exist 

for athletes, coaches, and parents? How does the large number of disparate leagues, 

teams, clubs and reactional opportunities available to young athletes complicate efforts to improve injury prevention? 

While youth sports are not nearly as far along as many professional leagues, 

progress has been made in recent years. All 50 States and the District of Columbia 

have enacted concussion laws and some youth sports organizations and leagues— 

such as Pop Warner Football, USA Hockey, US Soccer, to name a few—have implemented policies to reduce the amount of head contact in practices and games. Others—such as USA Football—provide education and guidance to enhance training 

and awareness for coaches, parents, and athletes. A number of these groups are repVerDate Mar 15 2010 14:08 Apr 25, 2017 Jkt 037690 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X145CONCUSSIONSPENDING WAYNE
4 

resented here today and I look forward to hearing how their efforts are affecting 

the safety of their respective sports. Based on their experience, thus far, are we 

doing enough? What does the science tell us? 

This last question is particularly interesting and important. There is a lot we do 

not know about concussions, generally, but pediatric populations, including youth 

sports, are severely underrepresented in existing research. And therein lays the 

challenge—the public wants answers that the science is not ready to provide. We 

have much to learn about how concussions and repetitive head injuries affect younger individuals, both immediately as well as later in life. Therefore, I am interested 

to learn more how youth sports organizations develop, review, and update their policies, guidance, or educational efforts in light of the limited, but rapidly evolving, research on concussions. If we don’t know how traumatic brain injury affects our 

youth, it makes it that much more challenging to protect them. 

Adding to the challenge, we currently lack any form of effective injury surveillance, including concussions, for athletes younger than high school age. Given the 

large number of athletes, teams, leagues, and other recreational opportunities, this 

is a daunting task. But if we do not understand the magnitude of the challenge, 

how different factors—such as age, gender, sport, socioeconomic status, etc.—influence outcomes, how can we ensure we are making the best decisions for our kids? 

This morning on our first panel, we are joined by two mothers—Ms. Kelli Jantz 

and Ms. Karen Zegel—both of whom tragically lost their sons as a result of injuries 

sustained while playing youth sports. Ms. Jantz’s son, Jake, was a promising freshman athlete at Grandview High School in Aurora, Colorado and is the namesake 

of Colorado’s ‘‘Jake Snakenberg Youth Concussion Act.’’ While Ms. Zegel’s son, Patrick Risha, was a star running back at Elizabeth Forward High School, in my district, and played football from the moment he could pick up a ball. We greatly appreciate their willingness to share their stories, as it reminds us why it is so vital 

that we continue to examine this issue. 

Later, on our second panel we will have Dartmouth’s Head Football Coach, Buddy 

Teevens, and representatives from some of the sports organizations—USA Football, 

USA Hockey, and US Lacrosse—that oversee or provide guidance to youth sports 

leagues. We will also hear from Practice Like Pros to learn more about additional 

options for keeping athletes safe. Additionally we have prominent researchers in 

this field that will be able to speak to how we can improve research and surveillance, better monitor injuries, and minimize the risk of injury based on the science. 

I appreciate all of our panelists for joining us this morning. This is an important 

issue and your perspectives are important to advancing the public dialogue on these 

complex injuries. 

I also would like to thank Ranking Member DeGette for her support on this initiative and look forward to continuing our efforts on this endeavor. I now recognize 

the Ranking Member for 5 minutes to deliver her own remarks. 

Mr. MURPHY. So I now recognize the ranking member for 5 minutes to deliver her own remarks. 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you so much, Mr. Chairman, for having 

this follow-up hearing on our roundtable that we held on concussions and brain trauma earlier this year. I am very pleased that 

we are looking, first, at youth sports through official hearings, because studies have shown that children and teens are more likely 

than adults to get a concussion, and they take longer to recover. 

Athletes at the professional college levels, they can make their 

own decisions about undertaking the risks associated with certain 

sports, but we need to ensure that children and their parents have 

enough data to make informed decisions about participation in 

youth contact sports. Part of that discussion needs to be the recognition of how valuable these sports are, both for physical fitness 

and team building, as you so well stated, Mr. Chairman. But I 

5 

think we also need to have an open discussion about how to make 

them safer. 

I approach this issue, both as a policymaker and a parent. And 

as I said in the roundtable, I support evidenced-based policy making and am very encouraged that we are having ongoing research 

to better understand brain trauma. But at our roundtable, the experts said that they are going to have answers about what the protocol should be in 7 to 10 years. And what I said at that hearing 

is, as a mom, when I’m deciding if my kid is going to play Pee Wee 

sports, I can’t afford to wait 7 to 10 years. By then, they will be 

in high school, and so we need to take whatever evidence that we 

have right now, and we need to figure out for now what we should 

tell the parents and what we should tell leagues that they should 

be doing as the best practices as far as we know right now. 

For example, at what age should children start playing tackle 

football? How many times a week should children be engaging in 

full contact practices? And when they do begin to play, how do we 

teach them to tackle safely and to protect their heads and the 

heads of other players? And how do we ensure that coaches are 

educated in teaching these skills to young players? I’m sure that 

we can ask other questions in all youth sports, not just football. 

I agree that most, if not all parents, would agree that it is better 

to err on the side of caution. The worst-case scenario would be that 

we discover later, that some of these safety measures may have 

been unnecessary. But as a mom, I always want to have more safety rather than less safety, especially when you’re talking about our 

children’s brains. 

Now, as we implement changes in sports now, this is not a reason to stop researching our gaps in knowledge. We need to understand the long-term effects of concussive and subconcussive injuries; we need to analyze whether the rule changes being implemented are having the desired effects; we need to study how to prevent brain injury in the first place. 

I also am interested from hearing in our witnesses on the second 

panel about the differences they are seeing in girls and boys sports 

and how the rates of concussion differ. I know that there have been 

studies suggesting that women and girls report concussions at 

higher rates than men and boys in similar sports. I want to know 

about that disparity, and also if there’s any disparity about the actual effects on brains. 

Both of our panels contain excellent witnesses, and it’s so important to have them today. I’m really proud to welcome two witnesses 

from Colorado. Kelly Jantz, as you heard, tragically lost her son 

Jake to second impact syndrome in 2004. 

And, Kelly, I’m so proud of you, because what you did is you 

were instrumental in ensuring that concussions are taken seriously 

in youth sports, and that parents and coaches have the information 

they need. As the chairman mentioned, in 2012, Governor 

Hickenlooper signed the Jake Snakenberg Youth Sports Concussion 

Act into law in Colorado, and we’re really proud that you’ve taken 

his legacy to that. We really are. 

Dr. Dawn Comstock is on our second panel. She’s from the Colorado School of Public Health. And like me, a Colorado native. She’s 

one of the leading experts in sports injury epidemiology. Her dataVerDate Mar 15 2010 14:08 Apr 25, 2017 Jkt 037690 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X145CONCUSSIONSPENDING WAYNE
6 

base gathers information on injury exposure and incidents among 

high school athletes. She looks at injury patterns like examining 

the correlation between neck strength and concussion risk to inform prevention and mitigation strategies. And so I want to thank 

you, also, Dr. Comstock, for making youth sports safer. 

I want to thank everybody who is here today to help us figure 

this out. And I also really want to say, we want to see sports succeed. I can’t let this hearing go by without congratulating the world 

champion Denver Broncos, for example, which I have season tickets. And I also want to say, as I said before, one of my great 

sadnesses is that I was unable to persuade either of my daughters 

to play ice hockey, and they took up dance instead. 

But the point is, all—every child in this country should be safe. 

We love sports. We want to see sports succeed, but that means that 

we have to do our utmost to improve player safety and guarantee 

that participation in sports doesn’t mean that you have long-term 

health consequences. 

So I know, Mr. Chairman, you intend to have more hearings. I 

think this is the perfect place to start. I want to thank you again, 

and yield back. 

Mr. MURPHY. Thank you. Go Steelers. 

Of course, right now the Penguins are in the playoffs. We wish 

them the best, too, and all athletes. 

I now am going to recognize—first of all, I want to say the opening statement of Mr. Upton will be included in the record. He could 

not be with us this morning. 

[The prepared statement of Mr. Upton appears at the conclusion 

of the hearing.] 

Mr. MURPHY. But we’re going to recognize Mr. Hudson for an 

opening statement. 

OPENING STATEMENT OF HON. RICHARD HUDSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NORTH 

CAROLINA 

Mr. HUDSON. Thank you, Mr. Chairman. I thank you, Chairman 

Murphy and Ranking Member DeGette, for your focus on this 

issue. Even as painful as it is to hear Representative DeGette talk 

about the Broncos, so I want to represent Charlotte, North Carolina, home of the Carolina Panthers. There’s always next year. 

I would like to thank the panelists for your important testimony 

today. Your experiences and expertise help the committee better 

understand the gravity of concussions in youth sports and what we 

need to do to prevent concussions and the long-lasting effects for 

future generations. 

Unfortunately, pediatric trauma, which concussions and traumatic brain injury is a part of, is the number-one killer of kids. Pediatric trauma has become a particular focus of mine. I’ve been fortunate to have the Childress Institute for Pediatric Trauma partner with me in examining what we can do to help our children live 

long, fulfilling lives. Childress Institute was started by my dear 

friend, Richard Childress’ wife Judy, with the goal of discovering 

and sharing in the best ways to prevent and treat severe injuries 

in children. The Childress Institute supports a number of pediatric 

research programs, including the Concussive Care Fund, which 

7 

funds initiatives prevent and treat injuries in youth and recreational sports. The promising research being done to prevent and 

treat trauma not only broadly, but also on specific issues like concussions, takes on particular importance to me as a father of a 7- 

month-old baby boy. I’m thankful so much awareness is being 

brought to this issue by discussions like today. 

As one trauma surgeon said to me, it’s not a life saved; it’s a lifetime saved. And I want to also note that my fellow North Carolina 

Representative, G.K. Butterfield and I are hosting a pediatric trauma briefing with the Energy and Commerce Committee on Tuesday, May 24th. I would encourage anyone who is interested to 

please attend, and I look forward to today’s discussion. 

With that, Mr. Chairman, I yield back. 

Mr. MURPHY. Is there anybody else on our side who have anything they want to add at this point? 

Then I now recognize the ranking member, Mr. Pallone, for 5 

minutes. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

And I want to thank all of our participants for joining us today. 

Additionally, I would like to thank the chairman for his commitment to this committee’s examination of concussions and brain 

trauma. Earlier this year, we had an initial roundtable on this 

issue, and at the time I requested to Chairman Upton that we hold 

a series of hearings on concussions and sports-related head trauma. 

I propose that we start with an examination of head impacts in 

youth sports, and I’m gratified that we are here today to discuss 

this very topic and look forward to the additional hearings on this 

important issue. 

Parents across the country are concerned about the risk of concussions, and with good reason. I have my own experience as a parent in dealing with my daughter’s concussion and deciphering the 

medical advice provided. It’s challenging as a parent to balance the 

news stories and the results of the latest research against the 

value of our children’s participation in sports, and I can certainly 

relate to parents’ concerns and their confusion about how to make 

the right decisions for their children. 

And there is compelling research to suggest that the effects of repeated head trauma, even those received during one’s youth, can 

accumulate and cause serious consequences, and these consequences can stem from injuries once considered minor known as 

subconcussive hits, or repetitive hits to the head. Purdue University Research is led by one of our witnesses today, Dr. Tom 

Talavage, found significant structural changes to the brains of high 

school football players, even among those who were not diagnosed 

with a single concussion. And what is particularly troubling is that 

these changes persist at even 12 months later, suggesting lasting 

damage. Many other studies have documented an association between subconcussive hits and changes in brain chemistry, decreased brain functioning, and behavioral changes. A recent study 

by a group of researchers at Boston University found that exposure 

8 

to hits, regardless of whether a concussion occurred, is Associated 

with a higher likelihood of mood disorders, like depression. Researchers have also repeatedly found evidence of the linkage between head impacts and CTE, a devastating degenerative brain 

disease. 

CTE has been found in former athletes as young as 25 years old 

and in adults who never played football beyond the high school 

level. And there remain a number of unanswered questions about 

what risk factors make individuals more susceptible to these debilitating conditions. We also need to understand what happens in the 

brain when it’s hit, and how many hits trigger these neurological 

effects. And while there is still research that needs to be done, that 

should not be an excuse for inaction. What is not in dispute is the 

association between head trauma from contact sports, such as football, and lasting brain damage in degenerative decisions, such 

CTE. Even the NFL publicly acknowledged this link at this committee’s roundtable back in March. 

Some researchers in this field suggest that we should, quote, 

‘‘wait on the science before making changes to the rules of youth 

sports.’’ And I respectfully disagree. We cannot ask children and 

their parents to wait 10, 15, or 20 years for the science to catch 

up before we take measures to make sports safer. We need to be 

asking questions right now and implementing the appropriate rule 

changes. 

The science has raised enough red flags about the dangers of repetitive head trauma that I think it is incumbent upon those who 

organize and promote youth contact sports to take every effort to 

make the games as safe as possible. And earlier this month, the 

subcommittee ranking member, Ms. DeGette, Mr. Green, and Ms. 

Schakowsky joined me in sending letters to collegiate and youth 

football leaders. We asked them to explain what rule or policy 

changes they are considering to address the risks associated with 

both concussive and subconcussive hits. And I expect that we will 

have a response by May 25th. And I commend Pop Warner for announcing yesterday that it would ban kickoffs in games starting 

this fall. 

I also look forward to hearing today from other youth sports organizations about what they are doing for their individual sports, 

and whether additional measures need to be considered. 

And last, Mr. Chairman, I want to express my deep thanks to 

both Kelly Jantz and Karen Zegel for joining us today. I can’t even 

imagine the losses you and your families have experienced. 

Thank you for your willingness to share your experiences with 

this committee. We can learn from you as we pave a path forward 

to better protect our kids. And thank you, again, to all our witnesses for their contribution and for helping us with our comprehensive review of concussions and head trauma. 

I hope we can all continue to work together to find the best ways 

to address this significant public health issue to protect our children. I yield back. 

[The prepared statement of Mr. Pallone follows:] 

9 

PREPARED STATEMENT OF HON. FRANK PALLONE

I want to thank all of our participants for joining us today. Additionally, I’d like 

to thank the chairman for his commitment to this committee’s examination of concussions and brain trauma. 

Earlier this year, we had an initial roundtable on this issue, and at the time, I 

requested to Chairman Upton that we hold a series of hearings on concussions and 

sports-related head trauma. I proposed that we start with an examination of head 

impacts in youth sports. I am gratified that we are here today to discuss this very 

topic, and I look forward to additional hearings on this important issue. 

Parents across the country are concerned about the risks of concussions, and with 

good reason. I have my own experience as a parent in dealing with a child’s concussion and deciphering the medical advice provided. It is challenging as a parent to 

balance the news stories and the results of the latest research against the value of 

our children’s participation in sports. I can certainly relate to parents’ concerns and 

their confusion about how to make the right decisions for their children. 

There is compelling research to suggest that the effects of repeated head trauma—even those received during one’s youth—can accumulate and cause serious consequences. And these consequences can stem from injuries once considered minor, 

known as subconcussive hits, or repetitive hits to the head. 

Purdue University researchers, led by one of our witnesses today, Dr. Tom 

Talavage, found significant structural changes to the brains of high school football 

players, even among those who were not diagnosed with a single concussion. What 

is particularly troubling is that these changes persisted even 12 months later, suggesting lasting damage. 

Many other studies have documented an association between subconcussive hits 

and changes in brain chemistry, decreased brain functioning, and behavioral 

changes. A recent study by a group of researchers at Boston University found that 

exposure to hits, regardless of whether a concussion occurred, is associated with a 

higher likelihood of mood disorders like depression. 

Researchers have also repeatedly found evidence of a linkage between head impacts and CTE, a devastating degenerative brain disease. CTE has been found in 

former athletes as young as 25 years old and in adults who never played football 

beyond the high school level. 

There remain a number of unanswered questions about what risk factors make 

individuals more susceptible to these debilitating conditions. We also need to understand what happens in the brain when it’s hit, and how many hits trigger these 

neurological effects. 

While there is still research that needs to be done, that should not be an excuse 

for inaction. What is not in dispute is the association between head trauma from 

contact sports, such as football, and lasting brain damage and degenerative diseases, such as CTE. Even the NFL publicly acknowledged this link at this committee’s roundtable back in March. 

Some researchers in this field suggest that we should ‘‘wait on the science’’ before 

making changes to the rules of youth sports. I respectfully disagree. We cannot ask 

children and their parents to wait 10, 15, or 20 years for the science to catch up 

before we take measures to make sports safer. 

We need to be asking questions right now and implementing the appropriate rule 

changes. 

The science has raised enough red flags about the dangers of repetitive head trauma that I think it is incumbent upon those who organize and promote youth contact 

sports to take every effort to make the games as safe as possible. 

Earlier this month, subcommittee Ranking Members DeGette, Green, and Schakowsky joined me in sending letters to collegiate and youth football leaders. We 

asked them to explain what rule or policy changes they are considering to address 

the risks associated with both concussive and subconcussive hits. I expect that they 

will respond to us by May 25th. And I commend Pop Warner for announcing yesterday that it would ban kickoffs in games starting this fall. I also look forward to 

hearing today from the other youth sports organizations about what they are each 

doing for their individual sports, and whether additional measures need to be considered. 

Last, I want to express my deep thanks to both Kelli Jantz and Karen Zegel for 

joining us today. I cannot even imagine the losses you and your families have experienced. Thank you for your willingness to share your experiences with this committee. We can learn from you as we pave a path forward to better protect our kids. 

Thank you again to all of our witnesses for your contributions and for helping us 

with our comprehensive review of concussions and head trauma. I hope we can all 

10 

continue to work together to find the best ways to address this significant public 

health issue to protect our children. 

Mr. MURPHY. The gentleman yields back. I ask unanimous consent that Members’ opening statements be introduced in the record. 

And, without objection, the documents will be entered into the 

record. 

Now, I would like to introduce the witnesses for our first panel 

for today’s hearing. We are going to try to get through their testimony before votes. 

The first witness on today’s panel is Ms. Kelly Jantz. Ms. Jantz, 

the mother of Jake Snakenberg. Jake passed away after suffering 

from second impact syndrome. Following her son’s death, Ms. Jantz 

has become a dedicated activist, committed to raising awareness of 

concussions in youth sports. We thank Ms. Jantz for preparing her 

testimony and look forward to her insights on these matters. 

I also want to welcome Ms. Karen Zegel. Ms. Zegel is the president of the Patrick Risha CTE Awareness Foundation. The Foundation was created in memory of her son, Patrick Risha, who I enjoyed reading about during his football career. He passed away 

after suffering from CTE. 

Thank you, Ms. Zegel, for your testimony today. We look forward 

to your comments. 

So you two are aware that this committee is holding the investigative hearing and when doing so has the practice of taking testimony under oath. 

Do either of you object to testifying under oath? Seeing no objections, the Chair then advises you that under the rules of the House 

and rules of the committee, you are entitled to be advised by counsel. 

Do either of you desire to be advised by counsel during your testimony today? 

Neither one does. In that case, would you mind, please, rising 

and raise your right hand, and I’ll swear you in. 

[Witnesses sworn.] 

Both answered affirmatively, and you are now under oath and 

subject to the penalties set forth in Title 18, section 1001 of the 

United States Code. 

I will ask you each to give a 5-minute summary of your written 

statement. There will be light in front of you which will be red 

when that time is up. 

You can begin, Ms. Jantz. Turn the microphone on and bring it 

very close to you if you don’t mind. Thank you. 

STATEMENTS OF KELLI JANTZ, MOTHER OF JAKE 

SNAKENBERG AND CONCUSSION AWARENESS ADVOCATE; 

AND KAREN KINZLE ZEGEL, MOTHER OF PATRICK RISHA 

AND CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE) 

AWARENESS ADVOCATE 

STATEMENT OF KELLI JANTZ 

Ms. JANTZ. Chairman Murphy, and Ranking Member DeGette, 

and members of the subcommittee, good morning and thank you for 

this opportunity to provide testimony on the important issue regarding youth and youth-related sports concussions. 

11 

I commend you and your colleagues on the work of this committee to shed light on this critical issue. My name is Kelli Jantz, 

and I’m the mom to Jake Snakenberg. My son was your typical allAmerican boy, devoted to sports, his friends, and our family. Jake 

was often referred to as our social butterfly in our family. He had 

a big heart and genuinely cared for those in his life. He had a joy 

about him that others could not resist. His big brother summed it 

up best when he said Jake drank up life like it was pouring from 

a fire hose. He gave 110 percent in everything, especially sports. 

On September 18th, in 2004, Jake got up at 6:15 in the morning 

in anticipation of his freshman football game. He loved football and 

all it offered; the physical challenge, the spirit of competition, and 

probably most of all, the friendships that were involved. He was 

particularly excited about playing in this game, because he had 

been held out of a few practices because the week prior, he had suffered an injury where his arms and hands went numb and tingly. 

What he described to us sounded like maybe he had tweaked his 

neck or strained his neck. He hadn’t lost consciousness; he didn’t 

see stars. You wouldn’t have associated it with a major type of injury. He didn’t report to his dad or me and any headaches during 

the week, though his friends had said that after that injury, he had 

complained of some headaches. Regardless of that, he was able to 

return to practices and meet the required number of practices to 

play on the game day. 

In warmups on the 18th, Jake took a really hard hit that really 

appeared to shake him. He noticed me looking on and waved me 

off to let me know he was oK. When the game began and he lined 

up for a play, right before the snap, Jake stumbled forward. A 

whistle was blown, and they called a penalty, and flag was thrown. 

And Jake got up and started to come to the sideline, and then 

stumbled and went down again, and he never got back up again. 

He was unconscious, and 911 was called immediately, and a life 

flight was dispatched to the football field. Jake was airlifted to 

Swedish Medical Center where a neurosurgeon advised us that 

Jake had could suffered a head injury, and steps were being taken 

to decrease the swelling in his brain. He told us that Jake may 

never play football again, and would likely have a long recovery. 

But he followed that statement with, if Jake survives this injury. 

Tragically, Jake didn’t survive. It was determined that Jake had 

suffered second-impact syndrome, a condition leading to rapid 

swelling of the brain from more than one concussion. It’s a phenomenon unique to young brains. 

It was likely that Jake had suffered a concussion the previous 

week. Subsequent hits during practice and warmups, though not 

associated with the concussion, had a compounding effect and continued to further injury his already compromised brain. 

Since Jake’s death, I have made it my mission to continue to 

raise awareness of the consequences of concussion in youth sports. 

Following Jake’s death, Dr. Karen McAvoy developed the REAP 

Project, which was adopted by a Rocky Mountain hospital for children and is made available to the Colorado Department of Education. This program deals with all youth concussions, regardless 

of the cause, meaning not just sports-related concussions, as any 

concussion can directly impact a student’s learning ability. 

12 

I’ve had the opportunity to support REAP Concussion Management Program, which is being adopted by other States through 

helping distribute the REAP manuals funded by the Jake 

Snakenberg Memorial Fund. 

Looking at the wealth of research on the consequences of youth 

concussion and the rapidly evolving advances in concussion management, we would be remiss and, actually, it would be irresponsible not to take every possible opportunity to develop measures to 

protect our youth from the devastating disabilities and potential 

death resulting from these types of injuries. 

To help—excuse me. I think, actually, in closing, these children 

are our future, and it’s our responsibility as parents and coaches, 

teachers, medical professionals, policymakers, and the community 

as a whole to make sure we do all we can to support the necessary 

culture change to make youth sports as safe as possible, and protect our children as well as to provide appropriate treatment and 

assistance should a concussion occur. 

I want to thank you, again, for addressing this critical issue and 

allowing me to participate in the hearing today. 

Mr. MURPHY. Thank you. 

[The prepared statement of Ms. Jantz follows:] 

13 


21158.001

TESTIMONY 

Before the 

Subcommittee on Oversight and Investigations 

House Committee on Energy and Commerce 

Hearing: 

Concussions in Youth Sports: Evaluating Prevention and Research 

Friday, May 13, 2016 

Chairman Murphy, Ranking Member DeGette, and Members of the Subcommittee: 

Good morning and thank you for this opportunity to provide testimony on the important issue 

regarding youth and sports-related concussions. I commend you and your colleagues on the work 

of this committee to shed light on this critical issue. My name is Kelli Jantz, and I am the mom to 

Jake Snakenburg. My son Jake was your typical all American boy. Devoted to sports, his friends, 

and our family Jake, was often referred to as our "social butterfly". He had a big heart, and 

genuinely cared for those in his life. He had a joy about him, that others could not resist. His big 

brother summed it up best when he said "Jake drank up life like it was pouring from a fire hose". 

He gave II 0% in everything, especially sports. 

On September 18,2004 our 14 year old son Jake Snakenburg got up at 6:15AM in anticipation of 

his football game. Jake loved football and all that it offered, the spirit of competition, the 

physical challenge and probably most of all the friendships. He was particularly excited about 

playing in this game as he had been held out of a few practices due to an injury from a prior 

game. Jake had suffered a hit which left his arms numb and tingly for a few minutes. From what 

he described we figured he had "tweaked" or strained his neck. He had not lost consciousness, or 

seen stars, no telltale signs of a major injury. He was monitored the following week and the 

range of motion in his neck improved. Jake did not inform his father or I of any headaches, but a 

few friends said Jake had complained of headaches during the week. Regardless, he was able to 

return to practice and meet the required number of practices to be eligible to play game day. 
14 


21158.002

In warm - ups on the 18'h, Jake took a hard hit that appeared to shake him. He noticed me 

looking on and waved me off to let me know he was ok. As the game began, Jake lined up with 

his team, but before the snap stumbled forward. The whistle was blown and penalty flag thrown. 

Slowly Jake got up and headed to the sideline, but collapsed on the field. He did not get up. Jake 

was unconscious. 911 was called immediately and life flight dispatched to the football field. Jake 

was airlifted to Swedish Medical. The neurosurgeon advised us that Jake had suffered a head 

injury and steps were being taken to decrease the swelling in his brain. He told us that Jake may 

never play his beloved football again, and will have a long recovery. The surgeon followed this 

statement with "if he survives this injury". Tragically Jake did not survive. It was determined 

that Jake had suffered what is called Second Impact Syndrome, a condition leading to rapid 

swelling from more than one concussion, a phenomenon unique to young brains. It is likely Jake 

suffered a concussion the previous week. The subsequent hits during warm ups, though not 

associated with a concussion had a compounding effect and continued to further injure his 

already compromised brain. 

Since Jake's death, I have made it my mission to continue to raise awareness of the 

consequences of concussion in youth sports. Following Jake's death, Karen McAvoy, Psy.D., 

developed the REAP Project which was adopted by the Rocky Mountain Hospital for Children 

and is made available to the Colorado Department of Education. The REAP Project is a 

community-based model for Concussion Management. REAP stands for Remove/Reduce 

physical and cognitive, or mental demands; Educate the student athlete, families, educators, 

coaches and medical professionals; Adjust/Accommodate for the student athlete academically; 

and Pace the student athlete back to learning, activitiy and play. However, the program addresses 
15 


21158.003

all youth with concussions, regardless of cause, meaning not just sports-related concussions, as 

any concussion can directly impact a student's learning ability. Educators, therefore, should 

understand the impact of concussions, as well as moderate to severe brain injury, will have with 

regard to academics. 

At least three states have passed legislation to begin addressing academic needs after a 

concussion, generally referred to as "return to learn", to bring these issues to the attention of 

educators. And, several states have developed training, resources and consultative teams to assist 

educators with screening, assessment, educational planning and support for children with brain 

injury regardless of severity. 

I have had the opportunity to support the REAP concussion management program which is now 

being adopted in other states. The REAP manuals have been funded for free distribution by the 

Jake Snakenburg Memorial Fund. I have also had the opportunity to testify in hearings leading to 

the passing of the Jake Snakcnburg Youth Concussion Act in 2011, which requires Colorado 

middle school, junior high and high school coaches, as well as volunteer coaches with regard to 

recreational sports, to be educated on how to recognize a concussion; to remove players from 

play, if a concussion is suspected; and to require the student athlete to be signed off by a medical 

professional before returning to play. All 50 states and the District of Columbia have passed 

similar legislation. 

Looking at the wealth of research on the consequences of youth concussion and the rapidly 

evolving advances in concussion management, we would be remiss, actually it would be 

irresponsible, not to take every possible opportunity to develop measures to protect our youth 

from the devastating disabilities and potential death resulting from these types of injuries. To 

help determine the extent and resulting problems, the Institute of Medicine and the National 
16 


21158.004

Research Council issued a report in October 2013 that called for the Centers for Disease Control 

and Prevention to establish and oversee a national surveillance system. 

Therefore, I support funding in the President's budget ($5 million) to implement the National 

Concussion Survellience Survey. Without comprehensive data, we will never know how many of 

our youth have been affected by concussions nor the short-term and long-term consequences. I 

ask Congress to please include $5 million in the FY2017 budget to allow the CDC to collect data 

on incidence and prevalence of concussions in youth population. I also support the passage of the 

Youth Sports Concussion Act, sponsored by the Congressional Brain Injury Task Force Cochairs, Representative Bill Pascrell and Representative Tom Rooney, to ensure that sports 

equipment is safe. 

In addition, I urge the U.S. Department of Education to provide assistance and support to state 

departments of education and public schools with regard to training educators to better address 

the academic needs of students with brain injury resulting in cognitive and behavioral problems. 

Schools should be encouraged to work with state and local agencies that provide services to 

individuals with brain injury in order to coordinate community resources and supports to families 

in order for children who are injured to have a successful recovery and outcome after brain 

injury. The National Association of State Head Injury Administrators (NASHIA) is one 

organization which can help identify state resources. 

In closing, these children are our future. lt is our responsibility as parents, coaches, teacher, 

medical professionals, policy makers and the community as a whole to make sure we do all we 

can to support the necessary culture change to make youth sports as safe as possible and protect 

our children, as well as to provide appropriate treatment and assistance once a concussion occurs. 

Thank you for addressing this critical issue and allowing me to participate in the hearing today. 
17 


21158.005

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

Subcommittee on Oversight and Investigations 

Hearing: 

Concussions in Youth Sports: Evaluating Prevention and Research 

Summary 

Kelli Jantz, Colorado 

The Centers for Disease Control and Prevention estimates 1.6 million to 3.8 million 

concussions occur each year. 

5-l 0% of athletes will experience a concussion in any given sport season . 

o Football is the most common sport with concussion risk for males (75% chance for 

concussion). 

o Soccer is the most common sport with concussion risk for females (50% chance for 

concussion). 

Headache (85%) and dizziness (70-80%) are most commonly reported symptoms 

immediately following concussions for injured athletes. 

All states have enacted youth sports concussion laws, referred to as "return to play" . 

o Colorado is one of thirteen states to extend concussion law requirements to private 

entities, such as private schools or youth athletic leagues, in addition to public 

schools. 

o Texas prohibits districts from using football helmets that are 16 years old or older. 

Helmets I 0 years old or older must be reconditioned at least every two years. 

At least 3 states have enacted "return to learn" laws in recognition of the impact of 

concussions on learning and academics. All states should implement similar programs to 

assess the learning abilities or difficulties following a concussion. 

Colorado has developed a concussion management program, called REAP, which is 

similar to other concussion management programs. However, not all states have the 

availability of such programs, or have them statewide. 

Educators need training to understand identification, assessment and educational 

strategies for students with brain injury, regardless of severity. 

Request Congress to include $5 million in the FY 2017 budget to allow the Centers for 

Disease Control and Prevention to implement the National Concussion Surveillance 

Survey in order to obtain data to determine the extent and impact of concussions. 

Request Congress to pass the Youth Sports Concussion Act, sponsored by Representative 

Pascrell and Representative Rooney, to ensure that sports equipment is safe. 

The U.S. Department of Education should provide opportunities for training and other 

assistance to assist educators in identification, assessment, and educational strategies for 

individuals with brain injury. 
18 

Mr. MURPHY. Ms. Zegel, you can go for 5 minutes. Thank you. 

STATEMENT OF KAREN KINZLE ZEGEL 

Ms. ZEGEL. Chairman Murphy, Ranking Member DeGette, and 

members of the committee, thank you so much for inviting me to 

speak today. My son, Patrick Risha, was a hometown hero in high 

school football. I’m going to cry. 

He grew up in an area that measured the worth of a man by his 

prowess and heart on the football field. He started just south of 

Pittsburgh, and with the Elizabeth Forward Youth Leagues when 

he was 10 years old. He was not gifted with size or speed, but 

nonetheless, worked hard to become a great player and through 

that, achieved his dream to go to an Ivy League school. It is that 

work ethic and perseverance in a collision sport that ultimately 

killed him. 

Patrick took his own life at the age of 32, but actually, we have 

come to know CTE took his life. Patrick never played in the NFL. 

Patrick was like millions of children before and after him that just 

played for fun and success in life. But throughout high school, prep 

school, and Dartmouth College, our sweet, tough, young running 

back received enough subconcussive blows to his head to essentially 

seal his fate. When he died, a newscaster friend of the family suggested he might have CTE. I had never heard of CTE before. I’ve 

had heard about NFL players having brain injuries and concussions, but I never dreamed it could affect a player at the college 

level. 

When Patrick’s autopsy revealed he had widespread CTE, I was 

in shock and horror. How many other players like Patrick are there 

out there? How many other families are dealing with a loved one 

gradually becoming unwired, with no clue what is happening? Not 

every grieving family has a newscaster friend saying the words 

CTE. 

For the sake of American families, this has to change. And we 

are grateful this committee is conducting this hearing to learn 

more about the disease, and the impact on families and on our society. 

Personally, I worried about Patrick becoming paralyzed, but I 

thought the chances were extremely small, and I thought he had 

so much to gain from playing. 

If I had known the repeated tackles my son endured were slowly 

killing him, I would have stopped it. No family wants their child 

to suffer a disease that causes him to lose his mind slowly, and 

with such anxiety and loneliness. Yet, every day, parents are signing their kids up for youth collision sports. These parents don’t understand the horror they may face with their child. Parents need 

to be told the truth. 

The human brain is much more fragile than we ever imagined. 

The brain doesn’t heal the way skin and bones do. Traumas could 

be very well permanent. For thousands of years, men have fought 

in arenas for sports and entertainment. Somehow we seem to have 

evolved to a point where we’re now willing to put children into arenas to tackle each other for sport. We put them in the equivalent 

of cheap Halloween costumes to emulate their NFL heroes. We ask 

19 

them to be tough little warriors. That’s what our family did, and 

we were so proud when Patrick carried his team to victory. 

Sadly, we lost an amazing young man before he ever had the 

chance to live his life, and gifted and promising young children like 

Patrick all over this land are winning battles on the sports field, 

but sadly losing their chances for a happy, healthy, productive future. 

Patrick’s tragic end was not an isolated incident. Parents need 

to know that one in three players may develop CTE. Soldiers coming home and ex-amateur collision athletes are being diagnosed 

with PTSD, ADHD, anxiety, depression, drug addictions, anger 

issues, et cetera, when, in fact, they may have CTE. 

When I see a guy on TV hitting his wife, shooting his friend, or 

going on a high-speed car chase, I wonder if maybe he played one 

too many football games. People need to know that this invisible 

disease is more common than we know, that it can develop in 

youth, high school, and college levels of collision sports. Families 

need to know what the causes and symptoms are, and how to address the disease. 

This has been hidden in plain sight for much too long. It was this 

realization that prompted us to form the Patrick Risha CTE 

Awareness Foundation and the Web site, stopCTE.org. We also created a brochure, Flag Until 14 to help parents understand the key 

issues of CTE. 

Heading the ball has recently been eliminated from youth soccer. 

Checking in hockey has been eliminated in youth leagues. Yet, over 

2 million children are still putting their precious brains at risk in 

tackle football. The urgency of this problem is beyond measure. I 

wish we would have known the truth 25 years ago. 

There are those out there who would prefer parents didn’t know 

about CTE. They will obfuscate the issue with unreasoned arguments. We’ve heard a few, like you can get a concussion riding a 

bike, or you’re turning our warriors into pansies, or do you want 

them to sit and play video games for the rest of their lives? When 

you have lost your son to CTE and you understand how it is caused 

and how prevalent it is, these arguments are hurtful and, in my 

opinion, keep children at risk. 

We see CTE as a human tragedy of immense proportions, and we 

need the help of everyone in this room and beyond. We all now 

have the duty to save children and families. CTE is 100 percent 

preventable. We need to remove repetitive head trauma from youth 

sports. To do anything else is to be complicit to the problem, knowing more families will suffer the pain we personally endure every 

day. 

Thank you very much. 

[The prepared statement of Ms. Zegel follows:] 

20 


21158.006

Testimony for Public Hearing 

"Concussions in Youth Sports: Evaluating Prevention and Research" 

Energy and Commerce Committee 

Oversight and Investigations Subcommittee 

May 13,2016 

Karen Kinzie Zegel 

31 Doyle St. 

Doylestown, PA 18901 

Thank you Energy and Commerce Committee members and particularly 

Representative Murphy for allowing me to speak to this hearing today. I consider it 

an honor and a privilege to represent the millions of children that are in harms way 

as we debate their future health and wellbeing. 

I am not a doctor or scientist. But I have experience. I have lived with and loved a 

person struggling with the disease Chronic Traumatic Encephalopathy, CTE. I have 

seen close-up the transformation of a beautiful, bright, energetic, loving young man 

into a reclusive, paranoid, depressed and angry person. It is heartbreaking. 

My son Patrick Risha was a hometown hero in high school football. He grew up in 

an area that measured the worth of a man by his prowess and heart on the football 

field. He started just south of Pittsburgh with the Elizabeth Forward youth leagues 

when he was ten years old. He was not gifted with size or speed but nonetheless 

worked hard to become a great player, and through that achieved his dream to go to 

an Ivy League school. It is that work ethic and perseverance in a collision sport that 

ultimately killed him. Patrick took his own life at the age of 32 .... But actually we 

have come to learn CTE took his life. 
21 


21158.007

Patrick never played in the NFL. Patrick was like millions of children before and 

after him that just played for success in life. But throughout high school, prep school 

and Dartmouth College, our sweet, tough, young running back received enough subconcussive blows to his head to essentially seal his fate. When he died, a newscaster 

friend of the family suggested he might have CTE. I had never heard of CTE before. I 

had heard about NFL players having brain issues but never dreamed it could have 

an effect at the level of a college player. When Patrick's autopsy revealed he had 

widespread CTE I was in shock and horror. How many other players like Patrick are 

there out there? How many other families are dealing with a loved one gradually 

coming unwired and have no clue what is happening? Not every grieving family has 

a newscaster friend saying the words CTE. For the sake of American families this 

has to change ..... and we are grateful this committee is conducting this hearing to 

learn more about the disease and the impact on families and on our society. 

People need to know that this disease is out there. That it can occur in youth and 

high school and college levels of collision sports. Families need to know what the 

symptoms are and how to address the disease. This has been hidden in plain sight 

for much too long. It was this realization that prompted our family and friends and 

the support of my husband, to form the Patrick Risha CTE Awareness Foundation 

and the website StopCTE.org. Sadly, I am not the only grieving loved one on this 

crusade. In March for Brain Injury Awareness Day here in the House twelve families 

were represented that lost loved ones to brain trauma and disease. Paul Bright, Eric 
22 


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Pelly, Daniel Brett and joseph Chernach only played football up to the high school 

level. Their moms and other families of CTE victims formed the Save Your Brain 

Campaign to bring attention to the need for protecting children in sports. Together 

with many other families (as the numbers grow), we will be returning to DC until we 

are sure that children are protected and safe. 

No family wants their child to suffer with a disease that causes them to lose their 

mind slowly and with such anxiety and loneliness. Yet everyday parents are signing 

their kids up for youth collision sports. Our "Steelers Country" area in Pennsylvania 

supports a television show called "Friday Night Tykes" with young children bashing 

heads on national television. These parents don't understand the horror that may 

face their child or they would not participate. 

Since Roman times MEN have fought in arenas for sport and entertainment. Yet 

somehow we seem to have evolved to the point where we are now willing to put 

children into arenas and tackle each other for sport. We put them in the equivalent 

of cheap Halloween costumes and we ask them to be tough little warriors. We did it. 

And we were so proud when Patrick carried his team to victory. Sadly we lost a 

gifted young man before he ever had a chance to live his life. And gifted children all 

over this land are winning battles on the sports fields but sadly losing their chances 

for a happy, healthy, productive life. 

If I had known the collisions my son endured were slowly killing him, I would have 
23 


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stopped it. Any parent would who knows the truth would stop it. Parents need to 

be told the truth. Parents need to know: 

• That 32% of amateur athletes in collision sports were found to have had CTE 

post mortem. 

• Parents need to know that helmets and sports equipment are unregulated 

and may even add to the likelihood of brain trauma in children. 

• Parents need to know that athletes that receive repetitive brain trauma 

before the age of 12 have significant changes in physiology, operations, and 

structure of the brain. So even if a child never gets CTE, he/she may still have 

done irreparable damage to the brain. Human brains are still developing 

until the age of 18 and sub-concussive blows to the head cause white matter 

changes, axon changes, and blood vessel changes, and these changes can be 

permanent. 

• Parents need to know that recognizing a concussion in a child is often very 

challenging. Kids won't even tell you when they are tired, let alone tell you if 

they have vision problems, sensitivity to noise, trouble concentrating, or feel 

emotionally changed. 

• Parents need to know that their child can develop CTE without ever receiving 

a concussion. 

• Parents need to know that less that half of youth football coaches are well 

trained in concussion management. Coaches do know that the team plays 

better when the best players are on the field. So where is the incentive in the 

heat of competition to do the right thing at the right time? 
24 


21158.010

Our Foundation created a brochure," Flag Until14" to help parents understand the 

key issues of CTE. We intend to place these brochures in every pediatrician office in 

the country. We have reached 62 practices so far. We have much more work to do. 

Heading the ball has recently been eliminated from youth soccer. Checking in 

hockey has been eliminated in youth leagues. Football needs to institute "Flag until 

14", at the very least. (We would prefer Flag Until SO) Now the information is out 

there. Now we need to pay attention to it. At the very least, we need to protect those 

precious little brains. Right now children need us to help protect them. 

There are those out there who would prefer parents didn't know about CTE. They 

will obfuscate the issue with unreasoned arguments. We've heard a few like "you 

can get a concussion riding a bike" or "you're turning our warriors into pansies" or 

"do you want them to sit and play video games for the rest of their lives?'' When 

you've lost your son to CTE, and you understand how it is caused, these arguments 

are insulting, and almost evil. So for now, please let's just help protect the kids. 

And what about the men and women who already have CTE? We believe that this 

silent epidemic may be playing out in millions of homes across this land. Families 

are burying loved ones all over this country thinking they died from suicide, drug 

addictions, PTSD, depression, ADHD, and irrational behaviors. Thinking that 

somehow something happened to change the person they loved, and feeling 

somehow that they failed them. Very few are linking these deaths to CTE ..... 
25 


21158.011

Maybe they don't know to ask. Maybe a doctor misdiagnosed the patient. Maybe the 

coroner is rushing to judgment. Maybe the behaviors in their loved ones changed so 

slowly that no one is linking it to previous military or sports history from so many 

years ago. Whatever the reasons, the silent epidemic continues. And we believe the 

magnitude of this horrific disease has yet to be discovered. Gunplay and murders 

are in the news every evening, and we always wonder how many of the perpetrators 

played collision sports or served in the military. just as many suicides are NOT 

reported every evening because of the stigma attached to suicide. We muffle the fact 

that a reported 22 veterans a day commit suicide, and that suicides exceed 

homicides every year. 

What also continues? Beautiful children are being placed in harms way through 

collision sports everyday. Families and loved ones are in turmoil. People arc losing 

their lives. Mental health practices, drug addiction facilities, and suicide centers are 

on overload. Lawyers are filing lawsuits all over the place. Insurances are going up. 

We also have some suggestions for better insight, research and ultimately help for 

victims and their families: 

• The CDC death certificate needs to have a box to check if the victim played a 

collision sport, and in turn the possibility for death from CTE should be noted 

on the death certificate. 

• The jails nation wide should do a study on how many inmates played a 

collision sport or were in the military. Rehab facilities should do the same. 
26 


21158.012

• Mental health providers need trained to recognize and treat CTE 

• No school or organization should field a collision sports team without a 

certified medical specialist on the field. 

In my sons memory, we set our mission to increase awareness of the insidious 

disease, CTE, and to help parents make informed decisions about the safety and 

welfare of our children, and to provide a resource to promote greater understanding 

of the challenge we face dealing with this silent epidemic. This is a human tragedy of 

immense proportions, but we are small and need the help of everyone in the room 

and in the halls of Congress. 

After we are done hearing everyone's testimony today we will know that children 

are in danger and need our help and that families are in crisis. Parents are receiving 

conflicting data and just don't know. We can't be the only doomsday placard holder 

in the street. Every person in this room now has the duty to save these children and 

families. CTE is 100% preventable. To do anything else is to be complicit to the 

problem and more families will suffer the pain we personally endure every day. 

Thank you so much for the opportunity to be a voice for children. 
27 

Mr. MURPHY. I thank both for that moving testimony. I think I’m 

just going to ask you one question. And that is, you mentioned that 

Patrick began playing football at age 10 and continued on. Do you 

know if his coaches, anybody working with the teams, had any specialized training to recognize, or be aware of concussions and injuries and discussed with his teammates? Do you know if there’s any 

of that training? 

Ms. ZEGEL. At that time, I knew most of the coaches personally, 

and I would have to guess no. I mean, we’re going back a ways before people starting talk about concussion. 

Mr. MURPHY. Even on the collegiate level, too? Even on the college level, too? 

Ms. ZEGEL. At the college level, as a parent, I was never informed of anything like that. 

Mr. MURPHY. OK. 

Ms. ZEGEL. I mean, that would have been nice to know then, but, 

no. 

Mr. MURPHY. Ms. Jantz, can you answer that, too? Any training 

you thought the youth coaches had to recognize, be aware of anything with concussions or head injuries? 

Ms. JANTZ. Not back in 2004 when Jake experienced this. Even— 

I mean, Jake’s stepfather and myself were both medical professionals, and while we understand, you know, obviously, hitting 

your head is a bad thing, we certainly didn’t have the background 

that we have now where you would have the opportunity to truly, 

you know, step back and look at it. Perhaps he would have been 

pulled and not played the next week. So I think that in those 

times, we did not have that, and now we have an opportunity to 

make sure that coaches and the people who are involved with our 

kids have all that information. 

Mr. MURPHY. Thank you. 

Ms. DeGette. 

Ms. DEGETTE. Thank you. Just following up on the chairman’s 

questioning. 

Ms. Jantz, I’ve been given this brochure. I think probably your 

Foundation was involved in helping put this together. Is that right? 

And it’s called, REAP, Remove/Reduce, Educate, Adjust/Accommodate Pace by the Center for Concussion at the Rocky Mountain 

Hospital for Children. And it really goes through a lot of information for educators and parents. 

Ms. JANTZ. Yes. 

Ms. DEGETTE. It’s a wonderful piece. I’m wondering, is this distributed? What do folks do with this? 

Ms. JANTZ. Well, we have a used that. It is distributed and available. We’ve made it available to school districts, to various groups, 

actually, I like to say anybody who I can get to listen, I will be 

happy to give that to. And it’s a comprehensive way of managing 

concussions, and it’s community-based. And it’s got a section for 

parents; and it’s got a section for medical professionals, and it has 

a section for the students and teachers. So everybody has a different piece in this. 

We’re not with our kids 24 hours a day. 

Ms. DEGETTE. Right. And, Ms. Zegel, you also have formed a 

foundation, an advocacy foundation. And I’m assuming that you’ve 

28 

also been working to get information like this out to parents, educators, coaches? 

Ms. ZEGEL. Right. Our current goal is—we’re working with medical examiners and coroners on one end, trying to get them to recognize the disease if they are presented with a drug overdose, or 

suicide, or something like that. Then on the other end, we’re trying 

to get—push for parents to have informed decisions that flag football is fun and—and it could be a lot of very famous football players never played until high school. 

Ms. DEGETTE. And you’ve got your brochure right next to you? 

Ms. ZEGEL. Yes, my daughter made that up. 

Ms. DEGETTE. Your daughter made that? That’s wonderful. Mr. 

Chairman, thank you so much. 

Ms. ZEGEL. Thank you. 

Ms. DEGETTE. And I would ask unanimous consent to put both 

of these brochures in. 

Mr. MURPHY. Without objection, that’s a great idea. Thank you. 

[The information appears at the conclusion of the hearing.] 

Ms. ZEGEL. Thank you. 

Ms. DEGETTE. Thank you for coming. 

Mr. MURPHY. Without objection. We want to thank our first 

panel. They have just called votes, so what we are going to do, we 

are going to take a break. Vote. I think we have three votes. We 

will do that as quickly as congressionally possible. We will come 

back. This will give the panel and opportunity to sit down and be 

ready. As soon as that last vote, I ask members to be back here 

immediately. We’ll get going, because our goal is to finish this 

hearing before the second set of votes. So we will work on that. 

Thank you, we will be recessed until votes are ended. Thank you. 

[Recess.] 

Mr. MURPHY. Could our witnesses please take their seats? 

All right. Thank you. We’re going to get moving right away because we know we’ve got another vote series, and we’d like to all 

give you the opportunity to testify. So I’d like to introduce the witnesses of our second panel for today’s hearing. 

We have Mr. Eugene Buddy Teevens to lead up our second panel. 

He has been head football coach at Dartmouth College since 2004, 

where he has implemented a policy of noncontact practices. I believe, Coach, you also were a teammate of the famous coach from 

Harvard University named Tim Murphy. He’s my twin. 

Next, we’d like to welcome Dr. Andrew Gregory. Dr. Gregory is 

here as a member of the Medical Advisory Committee for USA 

Football. 

Mr. Kevin Margarucci—did I say that correctly?—of USA Hockey. Mr. Margarucci has 20 yours of experience as a certified athletic trainer and now serves as the manager of player safety at 

USA Hockey. 

Next, we welcome Mr. Steve Stenersen. Mr. Stenersen has 

served as executive director and now president and CEO of USA 

Lacrosse since 1998. 

Next, we welcome Mr. Terry O’Neil. Mr. O’Neil is the founder 

and CEO of Practice Like Pros, whose mission is to educate high 

school coaches on alternative practice regiments. 

29 

Next, Dr. Dawn Comstock, who is an associate professor at Colorado School of Public Health and one of the Nation’s leading experts on high school injury surveillance. 

And finally, I’d like to introduce Dr. Thomas Talavage. 

Dr. TALAVAGE. Close enough. 

Mr. MURPHY. Is that close enough? What is the correct? Say it. 

Dr. TALAVAGE. Talavage. 

Mr. MURPHY. Talavage. I’ll get it right. 

Professor at the Weldon School of Biomedical Engineering at 

Purdue University. Dr. Talavage is also the founding codirector of 

Purdue’s MRI facility and a part of the Purdue Neurotrauma 

Group. 

Thank you to all the witnesses for being here today. I look forward to having a productive discussion. 

You’re all aware that the committee is holding an investigative 

hearing and when doing so has the practice of taking testimony 

under oath. Do you have any objections to testifying under oath? 

Seeing no objections, the Chair then advises you that under the 

rules of the House and rules of the committee, you’re entitled to be 

advised by counsel. Do any of you desire to be advised by counsel 

during your testimony today? 

And seeing no comments on that, then in that case, would you 

all please rise, raise your right hand, and I’ll swear you in. 

[Witnesses sworn.] 

Mr. MURPHY. Thank you. All witnesses have answered in the affirmative. And so now you’re all under oath and subject to the penalties set forth in Title 18, Section 1001 of the United States Code. 

I’m going to ask you all to give a 5-minute summary of you’re 

written statement. Please pay attention to the lights in front of you 

because we are on tight time for that. 

Mr. Teevens, you’re now recognized for 5 minutes. Coach, go 

ahead. Make sure your microphone is turned on and you pull that 

mike as close to you as possible, almost touching it. Thank you. 

STATEMENTS OF EUGENE F. (BUDDY) TEEVENS, III, HEAD 

FOOTBALL COACH, DARTMOUTH COLLEGE; ANDREW GREGORY, M.D., MEDICAL ADVISORY COMMITTEE MEMBER, USA 

FOOTBALL, AND ASSOCIATE PROFESSOR OF ORTHOPEDICS, 

NEUROSURGERY AND PEDIATRICS, VANDERBILT UNIVERSITY MEDICAL CENTER; KEVIN MARGARUCCI, MANAGER, 

PLAYER SAFETY, USA HOCKEY; STEVE STENERSEN, CEO, US 

LACROSSE; TERRY O’NEIL, FOUNDER/CEO, PRACTICE LIKE 

PROS; R. DAWN COMSTOCK, PH.D., ASSOCIATE PROFESSOR, 

DEPARTMENT OF EPIDEMIOLOGY, COLORADO SCHOOL OF 

PUBLIC HEALTH; AND THOMAS M. TALAVAGE, PH.D., PROFESSOR OF ELECTRICAL AND COMPUTER ENGINEERING, 

WELDON SCHOOL OF BIOMEDICAL ENGINEERING, PURDUE 

UNIVERSITY 

STATEMENT OF EUGENE F. (BUDDY) TEEVENS, III 

Mr. TEEVENS. Thank you, Mr. Chairman. I’d like to thank Kelli 

and Karen for their testimony as well. I think it underscores the 

importance of the committee. 

VOICE. Can you bring the mike closer? 

30 

Mr. TEEVENS. Closer? 

As I mentioned, I’d like to thank Karen and Kelli for their stories, and I think it underscores the importance of the committee 

and your task. 

My name is Buddy Teevens. I’ve been a college football coach for 

35 years. I’ve coached in the Ivy League, the SEC, the PAC–10, the 

Big Ten, Conference USA, and the Yankee Conference. During the 

course of summers, I work with all age groups, peewees right 

through high school-age kids. 

And football is a very special game. The life lessons with all the 

team sports, things people learn, the friendships they make, the experiences they have. I love the game of football, but I love my players more. 

And looking at concussive head injury through the course of 

time, I was—5 years ago, I made the decision that we were going 

to eliminate tackling from our practices, in-season practices, spring 

practices, pre-season practices. And the guarantee I make to parents is their son comes to Dartmouth, they will never tackle or be 

tackled by another Dartmouth football player for their 4 years. 

Now, making that decision, I wasn’t 100 percent sure I was doing 

the right thing. I worried about my players. Was I putting them 

at a competitive disadvantage? Was I preparing them fully for 

games? It was not a popular decision amongst my staff. It went 

from complete ridicule, to disbelief, to condemnation in some parties. 

I was convinced, however, I did a lot of research on it, that the 

way that we teach tackling was not the way that we tackle in 

games. And what I looked at, at length, was our defensive tape and 

how we actually tackled. And then we tried to replicate that tackling practice that we saw in games against pads, fitting them 

against other players without going to live concept, tackling sleds. 

We developed at Dartmouth, with the Thayer School of Engineering, a mobile tackling device, which has been quite beneficial in 

terms of actually replicating a moving target. 

With that, we actually tackle, I would say, more than anybody 

else in the country. Each of my players annually, 500 to 800 tackles per year, but never one against another human being. The only 

time our guys tackle are 10 games per year during the course of 

the season. 

What’s happened is our injury reduction has been phenomenal. 

Missed tackles, which we chart aggressively, dropped 50 percent 

the first year that we went to this nontackling process. And people 

ask me why, and it’s, quite simply, the skill of tackling, we practice 

more than we did when we were tackling live. It’s a shame, but in 

our sport, the most injurious act, tackling, is the one that’s practiced the least because of the fear of the risk of injury. 

So by putting our guys in a position to tackle with regularity, 

and this was unanticipated, we’ve become much more proficient at 

executing the act of tackling. You hear an awful lot about rugby 

tackling. I think football is a different sport. Shoulder tackling is 

a thing that we do preach. We don’t talk about the head other than 

say take it completely out of contact points. And it’s like riding a 

bike. You don’t just throw someone on a bike and let them start 

31 

to figure it out. There’s a process, training wheels and so on, support from parents. I do the same thing with our football players. 

A lot of folks ask me, well, can you do that at different levels? 

Without question. People look at the NFL, and I use them as a 

model. They hit less than anybody in the world and their concussive results in practice are probably some of the best. We’ve gone 

from a football team that struggled at times to we’re a championship team. We’ve won 17 games in the last 2 years, Ivy championship this year, and we had zero defensive concussive head injuries 

this season. And it’s all a process of how you present to your players. The buy-in has been appreciable. It’s been wonderful from a recruiting standpoint. 

Can other people use it? And I speak nationally with this. Prep 

school, Pop Warner school, youth football, they’ll say, well, how do 

you teach someone that’s never tackled a human being? Well, it’s 

a crawl, walk, run. Start with pads and progress forward. And I 

fully believe at any level that the approach we take—and I’d like 

to kick on a video right now, if I could. I think I’ve got time. And 

this will demonstrate more accurately than I could with words how 

we actually practice tackling. 

[video shown.] 

Mr. TEEVENS. We tackle literally every day that we practice and 

we put people in a position to execute the things that they would 

do on game day. A tackle’s different from position to position. A defensive lineman will not execute the same skill set that a defensive 

back will. And we’ve actually broken it down to levels of tackling, 

planes of tackling, and then repetitions that we have. The end result is we play at a very high level. We’ve been very, very successful and we’ve been very, very safe. 

[The prepared statement of Mr. Teevens follows:] 

32 


21158.013

Eugene F. Teevens Testimony before 

Congress of United States 

House of Representatives 

Committee of Energy and Commerce 

May 13,2016 

Thank you committee members for allowing me to address the Issue of concussions in youth 

sports. 

As a member of the football coaching profession for over 35 years I have worked at a number of 

colleges and universities and have Instructed young men on campuses and In high school and youth 

football camps every year. 

Football is a physical sport and the rfsk of injury is well known and documented. There has been 

an increased focus on the safety of the game particularly in the area of concussive head trauma. With 

concern for the health of my players at Dartmouth, I opted to eliminate all full contact live tackling of a 

teammate In all spring practice, pre-season and In season drills frve years ago. 

At that time, my decision was questioned heavily and not well received by my peers. The 

decision was not made lightly however. I weighed the possibiflty of putting our players at a competitive 

disadvantage and having them poorly prepared for full contact on game day; but believed that we could 

simulate game situations, without compromising performance, while reducing injury risk. 

With the help of the Dartmouth Football staff, we developed a practice plan that emphasized 

tackling technique and situations that our players would find themselves ln. We did this with greater 
33 


21158.014

specificity and repetition than we ever could in live tackling sessions. We use partners, pads, dummies, 

sleds and a mobile tackling device •MVP" developed with Dartmouth College's Thayer School of 

Engineering to teach, develop and practice proper form and execution. 

There has been some misunderstanding in the general public about our lack of tackling. We 

may, tackle more of than any other team In the country, we just never tackle each other. Our sole 

opportunity for full Uve tackling occurs on game day. I tell each of our recruited student athletes that 

they will never tackle or be tackled by a Dartmouth Football player during their career. 

The resulting Injury reduction from contact related practices has been significant, even at a time 

when concussive injury awareness, reporting, self-reporting by student athletes and their teammates Is 

as extensive as it has ever been. Peripheral injuries and missed practice time due to Injury have all 

dropped and has allowed our most talented players to be on the practice field and in game situations 

more regularly than before we switched to a non-live tackling operation. 

The past two seasons our record has been 17-3 and we earned a share of the Ivy league title 

this past fall. The practice protocol we follow has not hampered our development, quite the opposite. 

Dartmouth is a nationally ranked football program with a Division !leading defense. Our missed tackles 

per game is at an all-time low and we have had zero defensive concussive head injuries for the 2015 

season and through the recently concluded spring practice session. 

The Ivy league, under the leadership of Robin Harris, and by the unanimous vote of alllvy 

league Head Football Coaches recently eliminated all live tackling practices during the football season. 1 

believe every college conference In the country could adopt thls same policy without any negative 

impact on their athletes or the caliber of play. It is however, extremely difficult for Individual coaches to 

take such a step. 
34 


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For the past three years 1 have worked with "Practice like Pros," a group advocating reduction of 

contact in high school and youth football. I have spoken with hundreds of high school and youth 

football coaches about our practice approach. Questions that are frequently asked pertain to 

developing toughness, tackling skills, player evaluation and how to convince other coaches to try a 

different method of practicing. My response is simply the skills that we teach are the same ones firsttime players need to learn, practice and master. It is a •crawl, walk, run• progression. Those who want 

to "try" football are demonstrating the "toughness" many feel is needed to play. As coaches we can 

develop the confidence and skills needed to block and tackle gradually and not overwhelm "first timers• 

by putting them in extreme situations before they are comfortable and prepared to engage In them. 

As a profession, we are conservative and at times hesitant to change. We all care deeply about 

our sport, our players and the wonderful lessons and life experiences It can provide. This is an 

Important time in the long history of the game. As coaches, we need to decide whether we will wait for 

change, or become agents of change that must be made. 

What many are referring to as the "Dartmouth Way" is a viable means of reducing the amount 

of contact that players of any levels are exposed to. Understanding, teaching and practicing the most 

injurious aspects ofthe game, in a controlled environment, will eliminate countless "hits" to young men 

at all levels during the course of their careers and will create a safer environment for those who choose 

to play the game. 

Again, thank you for affording me this opportunity and best wishes as you carry out your 

important worlc. 
35 

Mr. MURPHY. Thank you very much. 

I now recognize Dr. Gregory for 5 minutes. 

STATEMENT OF ANDREW GREGORY 

Dr. GREGORY. Chairman Murphy and members of the subcommittee, my name is Dr. Andrew Gregory. I’m a pediatric sports 

medicine specialist at Vanderbilt University Medical Center. I’m a 

fellow of both the American Academy of Pediatrics and the American College of Sports Medicine, as well as a member of USA Football’s Medical Advisory Committee. I am not a USA Football employee, nor do I receive any compensation for being on the committee. I’m also a parent of an 18-year-old daughter who’s a soccer 

player. Thank you for the invitation to testify on USA Football’s behalf. 

In short, USA Football is the sport’s national governing body and 

a member of the U.S. Olympic Committee. It is an independent 

nonprofit organization. We create resources and direct programs establishing standards using the best available science, educating 

coaches, parents, and athletes. Our programs are endorsed by more 

than 40 organizations spanning medicine and sport, including the 

American College of Sports Medicine, the National Athletic Trainers’ Association, and the American Medical Society for Sports Medicine. 

I’d like to highlight three elements of how USA Football addresses player safety. The first of that is education. We train more youth 

and high school football coaches combined than any other organization in the U.S. Education is the core of our Heads Up Football program, which we’re going to highlight. This is delivered through online courses and in-person clinics. There are six educational components of this program, which you can see listed on the slide: Concussion recognition/response, heat preparedness and hydration, 

sudden cardiac arrest, proper equipment fitting, and then tackling 

and blocking techniques. 

More than 6,300 youth leagues and 1,100 high schools nationwide representing about a million young athletes enrolled in Heads 

Up Football in 2015. 

The second element is research. USA Football advances player 

safety by commissioning independent research. According to a 2014 

youth football study encompassing more than 2,000 players, 

leagues that participated in the Heads Up Football program 

showed a 76 percent reduction in all injuries during practice, 38 

percent reduction in all injuries during games, 34 percent fewer 

concussions during practice, and 29 percent decline in concussions 

during games. 

A subset of this group showed that players and leagues enrolled 

in Heads Up Football had two to three fewer head impacts of 10 

Gs or greater during practice, which may equate to more than 100 

fewer impacts in a season. 

On the high school level, Fairfax County Public Schools has reported a 43 percent decline in football-related concussions since 

2013 for 3,000 players since implementing Heads Up Football, and 

a 24 percent decline in overall football injuries. 

And, finally, we’ll highlight innovation. USA Football provides 

practice guidelines, practice planning tools, and defined levels of 

36 

contact. You can see the levels of contact listed there on the slide, 

including air; bag; control, which is a noncontact or nontaking 

down to the ground drill; thud, which is a controlled drill where 

you are not taken down to the ground, but there is contact; and 

then, finally, live action, where you are taken down to the ground. 

More young footballers than ever are learning the fundamentals 

of gradually and appropriately tackling before advancing to full 

contact. Where USA Football’s programs are in place, today’s youth 

and high school football is not the same as what it used to be for 

your children or what you may have watched. 

We’ll conclude with a video showing the difference that USA 

Football and Heads Up Football are making. 

[Video shown.] 

[The prepared statement of Dr. Gregory follows:] 

37 


21158.016

Testimony of 

ANDREW GREGORY, M.D., F.A.A.P., F.A.C.S.M. 

Medical Advisory Committee Member 

USA Football 

Associate Professor of Orthopedics, Neurosurgery & 

Pediatrics 

Vanderbilt University Medical Center 

Before the House Subcommittee on Oversight and 

Investigation 

"Concussions in Youth Sports: Evaluating Prevention and 

Research" 

May 13, 2016 
38 


21158.017

Chairman Murphy and Members of the Committee: 

My name is Dr. Andrew Gregory. I am a pediatric sports medicine specialist at 

Vanderbilt University Medical Center. I am a fellow of both the American Academy of 

Pediatrics and the American College of Sports Medicine as well as a member of USA Football's 

Medical Advisory Committee. I have served USA Football in this capacity since 2013. I am not 

a USA Football employee nor do I receive compensation for being on the committee. 

USA Football is the sport's national governing body and a member of the U.S. Olympic 

Committee. We do not operate youth football leagues nor lead high school teams. We create 

resources and direct programs that establish important standards using the best available 

science, educating coaches, parents and young athletes who play football. 

Our programs are endorsed by more than 40 organizations spanning medicine and 

sport, including the American College of Sports Medicine, the National Athletic Trainers' 

Association and the American Medical Society for Sports Medicine. 
39 


21158.018

USA Football is an independent nonprofit organization that works in partnership with 

the NCAA, NFL, National Federation of State High School Associations and Pop Warner Little 

Scholars, among others. 

The purpose of this testimony is to outline three key elements of how USA Football 

advances concussion prevention and research for the good of young athletes who play our 

sport and gain its fitness and social benefits. These three key elements are education, 

research and innovation. 

4 
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21158.019

EDUCATION 

USA Football trains more youth and high school football coaches combined than any 

organization in the United States. 

Education has the power to change behavior for the better. This is the core of USA 

Football's Heads Up Football program, delivered through online courses, in-person clinics and 

continuing education opportunities. 

Its six educational components are: 

CDC-approved concussion recognition and response 

Heat preparedness and hydration 

Sudden cardiac arrest protocols 

Proper equipment fitting 

Tackling techniques 

Blocking techniques 

Heads Up Football was introduced nationally to youth football organizations in 2013 and 

to high schools in 2014. More than 6,300 youth leagues and 1,100 high schools spanning all 
41 


21158.020

50 states and Washington, D.C., representing approximately 1 million players, enrolled in 

Heads Up Football in 2015. 

Coaches enrolled in the program complete hands-on, in-person instruction as well as an 

online curriculum covering the topics bulleted above. USA Football also trains one 

representative from each school or youth organization to serve as its Player Safety Coach, 

reinforcing the program's teachings, guiding practices as needed throughout the season, 

seeing the skills put into action at games and serving as a resource for players, parents and 

coaches. 

Every youth football coach within an organization enrolled in Heads Up Football is 

trained how to teach the game's fundamentals by completing USA Football's nationally 

accredited Level 1 Coaching Certification Course. High school coaches gain training through 

USA Football's High School Coach Certification course, developed in partnership with the 

National Federation of State High School Associations. 

Heads Up Football is endorsed by 14 state high school associations and 11 state high 

school coaches associations. The Oregon State Activities Association this year is requiring all 

6 
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21158.021

football coaches in its 249 football-playing member high schools to participate in Heads Up 

Football prior to the start of the 2016 season. 

Dr. Michael Koester, Chairman of the Oregon School Activities Association Sports 

Medicine Advisory Committee said: 

"The really exciting thing about this program is what happens at the high school 

level will spread throughout the youth programs in each community. This will 

allow kids to develop their skills in a culture that shares the same language, 

same techniques and same safety standards from grade school through high 

school .... The committee sees this as a natural next step as we look to 

innovative ways to minimize the risk of all football injuries, but particularly 

concussions. This is an opportunity for high school coaches to set a standard for 

the youth leagues in their communities across the state. Ideally, we'll have 

youth coaches getting certified as well, allowing for continuity of tackling 

techniques and safety protocols through an athlete's entire playing experience." 

More on USA Football's Heads Up Football program may be found at 

www.usafootball.com/headsup. 

USA Football also has been honored nationally for its work to advance athlete safety by 

the National Athletic Trainers' Association (NATA), the professional membership association for 

certified athletic trainers and others who support the athletic training profession. Founded in 

1950, the NATA has grown to more than 43,000 members worldwide today. In March of this 

7 
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21158.022

year, USA Football became the First national governing body of a sport to earn the NATA's 

Youth Sport Safety Ambassador Award for demonstrating significant contributions to the 

health and welfare of secondary school student-athletes. NATA's prestigious Youth Sports 

Safety Award recognizes those who have advanced athlete safety by providing exemplary 

youth sports safety protocols and advancing the provision of medical care, research, policy 

change and resource allocation. Along with USA Football, Project ADAM, and U.S. 

Representative Bill Pascrell, Jr., also were recognized with this honor in March 2016. More 

details can be found about this award at http://www.nata.org/press-release/031516/natapresents-2 0 16-you th-spa rts-safety-am bass ado r-aw a rds-sev enth-ann u a !-youth . 

Due in part to USA Football's medically endorsed programs and innovations, youth and 

high school football is changing for the better. 

* * * 

RESEARCH 

USA Football advances player safety through supporting independent third-party 

research. 

8 
44 


21158.023

According to a 2014 Datalys Center for Sports Injury Research and Prevention study, 

encompassing more than 2,000 youth football players, when compared to leagues that did not 

employ Heads Up Football, players in leagues that did participate in the program showed: 

76 percent reduction in all injuries during practices 

38 percent reduction in all injuries during games 

34 percent decline in concussions during practices 

29 percent decline in concussions during games 

The peer-reviewed study was published by The Orthopaedic Journal of Sports Medicine 

in July 2015. 

A subset of this study encompassing 70 youth players showed that over the course of a 

season, those in leagues enrolled in Heads Up Football had 2-to-3 less head impacts of lOg or 

greater per practice compared to those in non-Heads Up Football leagues. This may prevent 

more than 100 such impacts over the course of a 12-week season. 

"This is compelling data," Datalys Center President and Injury Epidemiologist Dr. 

Thomas Dampier said. "I am actually surprised by the strength of the association but 

9 
45 


21158.024

completely confident in our findings. It's logical in the first two years of research, we found 

that coach and player behavior was predictive of injury even though we hypothesized 

differently. That led us to pursue a third year of research to examine if coach education 

reduced injuries and head impacts, and we found that this was the case." 

Dampier continued: "If we had found that only injury rates or only head impacts were 

reduced but not both, I would not have been as confident with our results. However, 

combined with the first two years of data that pointed at coach and player behavior, these 

current data indicate that coach education can have a positive impact on player safety and 

may serve as a model for youth sports like soccer, ice hockey, lacrosse and others concerned 

with concussion and head impact risk." 

On the high school level, Fairfax County Public Schools, the lOth largest school district 

in the country, has employed Heads Up Football since 2013. In this time, the district has 

reported a 43.3 percent decline in concussions among its 3,000 football-playing studentathletes. During this same time span with all 25 of its high school programs enrolled in Heads 

Up Football, overall football injuries have declines 23.9 percent. Data was collected by Fairfax 

10 
46 


21158.025

County Public Schools' athletic trainers. "We have one consistent match of what we're talking 

about, of how we're teaching our athletes to play the game. From ankle biter through 12th 

grade, we have one consistent curriculum," said Bill Curran, Director of Student Activities and 

Athletics for Fairfax County School District. "We're able to show with data that there's a 

difference. You know, Centreville High School played in back-to-back state championships and 

had the fewest injuries of our 25 high schools. That's a big deal." 

Similarly, high schools within the South Bend (Ind.) Community School Corporation 

(SBCSC), with approximately 1,000 football-playing student-athletes, reported concussions 

from football to decline by 40 percent from 2014 to 2015, the first year the school system 

implemented Heads Up Football district-wide. Although football participation increased across 

the district from 1,000 student-athletes to 1,037 during this time, concussions from football 

decreased from 53 to 32. Concussion data was recorded by the high schools' athletic trainers. 

"USA Football's 'Heads Up Football' program has been invaluable to us and we are so happy to 

have had the opportunity to become a part of the program," SBCSC Athletic Director Kirby 

Whitacre said. 

II 
47 


21158.026

USA Football is committed to continue commissioning independent studies into youth 

and high school player health and safety. 

* * * 

INNOVATION 

USA Football provides practice guidelines, practice planning tools and defined Levels of 

Contact (www.usafootball.com/health-safety/levels-of-contact) for tackle coaches to properly 

teach player techniques in a progressive manner. More young football players than ever before 

are learning the fundamentals in a gradual and appropriate manner prior to advancing to full 

contact. Endorsed by the American College of Sports Medicine, the American Medical Society 

for Sports Medicine and the National Athletic Trainers' Association, USA Football's Youth 

Practice Guidelines set important standards for preseason heat acclimatization, regulating 

practice intensity and maintaining hydration levels to reduce the risk of injury and create the 

best environment for our children. 

Among its pillars: 

No two-a-day practices in preseason or regular season 

12 
48 


21158.027

Graduated equipment and contact levels in preseason to properly 

acclimate players to exercise and heat 

No more than two hours of practice in any day 

No more than four football activity days per week, including practices and 

games 

No more than 30 minutes of Live Action or "Thud" level contact per day 

USA Football's Levels of Contact focus on varying intensity levels throughout practices 

to build player confidence, ensure their safety and prevent both physical and mental 

exhaustion. Five intensity levels are used to introduce players to practice drills which position 

them to master the fundamentals and increase skill development. 

Air- Players run a drill unopposed and without contact 

Bags- Drill is run against a bag or other soft-contact surface 

Control - Drill is run at assigned speed with predetermined winner. 

Contact remains above the waist and players stay on their feet. 

13 
49 


21158.028

Thud - Drill is run at competitive speed with no predetermined winner. 

Players stay on their feet and a quick whistle ends the drill. It is important to note that 

USA Football considers "Thud" to be a full-contact level and limits the time that coaches 

can run drills at this speed and intensity. Other organizations - including the Ivy League 

and other college programs - do not include "Thud" as full contact. 

Live action - Game-like conditions and the only time players are taken to 

the ground. 

Through innovations such as the Youth Practice Guidelines and Levels of Contact, 

coaches instruct their players through a series of USA Football-developed drills to build 

confidence and instill the proper fundamentals. Through a player progression development 

model, players leam the right stage at the right age, using the same terminology as they 

mature mentally, physical and emotionally. 

USA Football's Heads Up Tackling technique teaches young athletes to make contact 

with their shoulders in an ascending strike and rip their arms up through the ball-carrier, 

grabbing the backside of the jersey -thus keeping the head and eyes up through the process. 

14 
50 


21158.029

Likewise, USA Football's Heads Up Blocking technique takes a player from stance to steps to 

contact, using their hands - not their helmets to drive opponents out of the way. Laying the 

basic foundations, Heads Up Tackling and Heads Up Blocking fundamentals can be used to 

teach every type of tackle and block that a player needs to learn. 

As Dr. Jon Devine, president of the American Medical Society for Sports Medicine, said: 

"We endorsed USA Football's Heads Up Football program in 2014, and it continues to advance 

player safety and change behavior for the better. Young athletes are safer when their coaches 

are trained, proper fundamentals are taught and protocols in the best available science are put 

into motion. Creating a program like Heads Up Football takes leadership- leadership one 

would expect from a national governing body of sport." 

USA Football works every day to improve education, establish research and pave 

innovation toward creating a better, safer game for the young athletes who enjoy the fun, 

exercise and social benefits of an exceptional team sport. 

# # # 

15 
51 


21158.030

The Honorable Tim Murphy 

Chairman 

Subcommittee on Oversight and 

Investigations 

2125 Rayburn House Office Building 

Washington, DC 20515-6115 

The Honorable David McKinley 

Vice Chairman 

Subcommittee on Oversight and 

Investigations 

2125 Rayburn House Office Building 

Washington, DC 20515-6115 

Dear Honorabte Representatives, 

june 30, 2016 

The Honorable Diana DeGette 

Ranking Member 

Subcommittee on Oversight and 

Investigations 

2125 Rayburn House Office Building 

Washington, DC 20515-6115 

On May 12,2016, USA Football submitted the written Testimony of Andrew Gregory, MD and 

PowerPoint slides in advance of his testimony the following day at the House 

Subcommittee on Oversight and Investigation hearing entitled "Concussions in Youth 

Sports: Evaluating Prevention and Research." 

The written testimony and one of the slides we submitted erroneously cited results from a 

preliminary analysis of the data and not the results that were peer-reviewed and published 

in The Orthopaedic journal of Sports Medicine in July 2015. The peer-reviewed and 

published results account for the positive effect of the Pop Warner Practice Guidelines- a 

second intervention that confounded the preliminary analysis. The correction may be 

found at page 5 of the enclosed corrected submission. Both sets of data support the 

efficacy of Heads Up Football in reducing injuries in youth football. 

We apologize for the error and request that you update the record with this corrected 

version. 

Sincerely yours, 

buc~ Senior Director, Communications 

Cc: Andrew Gregory, MD 

Enclosure 

USA Football 1 45 N. Pennsylvania St., .suite 700 1 Indianapolis, !N 46204 I Tel (317) 614-7750 J F<:~x {317) 614-7751 I usafootbalLrnm 
52 


21158.031

Testimony of 

ANDREW GREGORY, M.D., F.A.A.P., F.A.C.S.M. 

Medical Advisory Committee Member 

USA Football 

Associate Professor of Orthopedics, Neurosurgery & 

Pediatrics 

Vanderbilt University Medical Center 

Before the House Subcommittee on Oversight and 

Investigation 

"Concussions in Youth Sports: Evaluating Prevention and Research" 

May 13, 2016 (as corrected June 30, 2016) 
53 


21158.032

Chairman Murphy and Members of the Committee: 

My name is Dr. Andrew Gregory. I am a pediatric sports medicine specialist at Vanderbilt 

University Medical Center. I am a fellow of both the American Academy of Pediatrics and the American 

College of Sports Medicine as well as a member of USA Football's Medical Advisory Committee. I have 

served USA Football in this capacity since 2013. I am not a USA Football employee nor do I receive 

compensation for being on the committee. 

USA Football is the sport's national governing body and a member of the U.S. Olympic 

Committee. We do not operate youth football leagues nor lead high school teams. We create 

resources and direct programs that establish important standards using the best available science, 

educating coaches, parents and young athletes who play football. 

Our programs are endorsed by more than 40 organizations spanning medicine and sport, 

including the American College of Sports Medicine, the National Athletic Trainers' Association and the 

American Medical Society for Sports Medicine. 

USA Football is an independent nonprofit organization that works in partnership with the 

NCAA, NFL, National Federation of State High School Associations and Pop Warner Little Scholars, 

among others. 

The purpose of this testimony is to outline three key elements of how USA Football advances 

concussion prevention and research for the good of young athletes who play our sport and gain its 

fitness and social benefits. These three key elements are education, research and innovation. 

2 
54 


21158.033

EDUCATION 

USA Football trains more youth and high school football coaches combined than any 

organization in the United States. 

Education has the power to change behavior for the better. This is the core of USA Football's 

Heads Up Football program, delivered through online courses, in-person clinics and continuing 

education opportunities. 

Its six educational components are: 

CDC-approved concussion recognition and response 

Heat preparedness and hydration 

Sudden cardiac arrest protocols 

Proper equipment fitting 

Tackling techniques 

Blocking techniques 

Heads Up Football was introduced nationally to youth football organizations in 2013 and to 

high schools in 2014. More than 6,300 youth leagues and 1,100 high schools spanning all 50 states and 

Washington, D.C., representing approximately 1 million players, enrolled in Heads Up Football in 2015. 

Coaches enrolled in the program complete hands-on, in-person instruction as well as an 

online curriculum covering the topics bulleted above. USA Football also trains one representative 

from each school or youth organization to serve as its Player Safety Coach, reinforcing the program's 

teachings, guiding practices as needed throughout the season, seeing the skills put into action at 

games and serving as a resource for players, parents and coaches. 

Every youth football coach within an organization enrolled in Heads Up Football is trained how 

to teach the game's fundamentals by completing USA Football's nationally accredited Level 1 

Coaching Certification Course. High school coaches gain training through USA Football's High School 
55 


21158.034

Coach Certification course, developed in partnership with the National Federation of State High 

School Associations. 

Heads Up Football is endorsed by 14 state high school associations and 11 state high school 

coaches associations. The Oregon State Activities Association this year is requiring all football 

coaches in its 249 football-playing member high schools to participate in Heads Up Football prior to 

the start of the 2016 season. 

Dr. Michael Koester, Chairman oft he Oregon School Activities Association Sports Medicine 

Advisory Committee said: 

"The really exciting thing about this program is what happens at the high school level 

will spread throughout the youth programs in each community. This will allow kids to 

develop their skills in a culture that shares the same language, same techniques and 

same safety standards from grade school through high school. ... The committee sees 

this as a natural next step as we look to innovative ways to minimize the risk of all 

football injuries, but particularly concussions. This is an opportunity for high school 

coaches to set a standard for the youth leagues in their communities across the state. 

ideally, we'll have youth coaches getting certified as well, allowing for continuity of 

tackling techniques and safety protocols through an athlete's entire playing 

experience." 

More on USA Football's Heads Up Football program may be found at ww~w.usafootbalLcomlbeadsup. 

USA Football also has been honored nationally for its work to advance athlete safety by the 

National Athletic Trainers' Association (NATA), the professional membership association for certified 

athletic trainers and others who support the athletic training profession. Founded in 1950, the NATA 

has grown to more than 43,000 members worldwide today. In March of this year, USA Football became 

the first national governing body of a sport to earn the NATA's Youth Sport Safety Ambassador Award 

for demonstrating significant contributions to the health and welfare of secondary school studentathletes. NATA's prestigious Youth Sports Safety Award recognizes those who have advanced athlete 

safety by providing exemplary youth sports safety protocols and advancing the provision of medical 

care, research, policy change and resource allocation. Along with USA Football, Project ADAM, and U.S. 

Representative Bill Pascrell, Jr., also were recognized with this honor in March 2016. More details can 

4 
56 


21158.035

be found about this award at http:/Jwww.nata.orgLpresscreleaseL031S16lnata~resents-2016:cyoutbo 

Due in part to USA Football's medically endorsed programs and innovations, youth and high 

school football is changing for the better. 

*** 

RESEARCH 

USA Football advances player safety through supporting independent third-party research. 

According to a 2014 Oatalys Center for Sports Injury Research and Prevention study, 

encompassing more than 2,000 youth football players, when compared to leagues that did not 

employ Heads Up Football, players in leagues that did participate in the program showed: 

201S. 

87% lower injury rates during practice in organizations with Heads Up Football 

coach education plus Pop Warner practice guidelines that limit contact 

63% lower injury rates during practice with Heads Up Football coach education 

only compared to those with no coach education or practice guidelines 

82% lower concussion rate during practice with Heads Up Football coach 

education and Pop Warner practice guidelines that limit contact among 11-1S 

year-old athletes' 

The peer-reviewed study was published by The Orthopaedic Journal of Sports Medicine in July 

A subset of this study encompassing 70 youth players showed that over the course of a 

season, those in leagues enrolled in Heads Up Football had 2::to_,3.Jessbead_impacts of 10g or greater 

1 The written testimony submitted May 12,2016 erroneously used results from Datalys' preliminary 

analysis of the data. The results cited here are results that were peer-reviewed and published and 

reflect the positive effect of the Pop Warner Practice Guidelines- a second intervention that 

confounded the preliminary analysis. See Zachary Y. Kerr et al., "Comprehensive coach education and 

practice contact restriction guidelines result in lower injury rates in youth American football." 3(7) 

Orth. J. Sports Med 232S96711SS94S78 (Jul. 1, 201S). 
57 


21158.036

per practice compared to those in non-Heads Up Football leagues. This may prevent more than 100 

such impacts over the course of a 12-week season. 

"This is compelling data," Datalys Center President and Injury Epidemiologist Dr. Thomas 

Dampier said. "I am actually surprised by the strenglh of the association but completely confident in 

our findings. It's logical- in the first two years of research, we found that coach and player behavior 

was predictive of injury even though we hypothesized differently. That led us to pursue a third year of 

research to examine if coach education reduced injuries and head impacts, and we f!!ound that this 

was the case." 

Dampier continued: "If we had found that only injury rates or only head impacts were reduced 

but not both, I would not have been as confident with our results. However, combined with the first 

two years of data that pointed at coach and player behavior, these current data indicate that coach 

education can have a positive impact on player safety and may serve as a model for youth sports like 

soccer, ice hockey, lacrosse and others concerned with concussion and head impact risk." 

On the high school level, Fairfax County Public Schools, the 10th largest school district in the 

country, has employed Heads Up Football since 2013.1n this time, the district has reported a 43.3 

percent decline in concussions among its 3,000 football-playing student-athletes. During this same 

time span with all25 of its high school programs enrolled in Heads Up Football, overall football 

injuries have declines 23.9 percent. Data was collected by Fairfax County Public Schools' athletic 

trainers. "We have one consistent match of what we're talking about, of how we're teaching our 

athletes to play the game. From ankle biter through 12th grade, we have one consistent curriculum," 

said Bill Curran, Director of Student Activities and Athletics for Fairfax County School District. "We're 

able to show with data that there's a difference. You know, Centreville High School played in back-toback state championships and had the fewest injuries of our 25 high schools. That's a big deal." 

Similarly, high schools within the South Bend (Ind.) Community School Corporation (SBCSC), 

with approximately 1,000 football-playing student-athletes, reported concussions from football to 

6 
58 


21158.037

decline by 40 percent from 2014 to 2015, the first year the school system implemented Heads Up 

Football district-wide. Although football participation increased across the district from 1,000 

student-athletes to 1,037 during this time, concussions from football decreased from 53 to 32. 

Concussion data was recorded by the high schools' athletic trainers. "USA Football's 'Heads Up 

Football' program has been invaluable to us and we are so happy to have had the opportunity to 

become a part of the program," SBCSC Athletic Director Kirby Whitacre said. 

USA Football is committed to continue commissioning independent studies into youth and 

high school player health and safety. 

• •• 

INNOVATION 

USA Football provides practice guidelines, practice planning tools and defined Levels of 

Contact (www.lisafootball.com/health-safetyLlevels-of,contact) for tackle coaches to properly teach 

player techniques in a progressive manner. More young football players than ever before are learning 

the fundamentals in a gradual and appropriate manner prior to advancing to full contact. Endorsed 

by the American College of Sports Medicine, the American Medical Society for Sports Medicine and 

the National Athletic Trainers' Association, USA Football's Youth Practice Guidelines set important 

standards for preseason heat acclimatization, regulating practice intensity and maintaining hydration 

levels to reduce the risk of injury and create the best environment for our children. 

Among its pillars: 

No two-a-day practices in preseason or regular season 

Graduated equipment and contact levels in preseason to properly acclimate 

players to exercise and heat 

No more than two hours of practice in any day 

No more than four football activity days per week, including practices and 

games 

No more than 30 minutes of Live Action or "Thud" level contact per day 

7 
59 


21158.038

USA Football's Levels of Contact focus on varying intensity levels throughout practices to build 

player confidence, ensure their safety and prevent both physical and mental exhaustion. Five 

intensity levels are used to introduce players to practice drills which position them to master the 

fundamentals and increase skill development. 

Air- Players run a drill unopposed and without contact 

Bags- Drill is run against a bag or other soft-contact surface 

Control- Drill is run at assigned speed with predetermined winner. Contact 

remains above the waist and players stay on their feet. 

Thud- Drill is run at competitive speed with no predetermined winner. Players 

stay on their feet and a quick whistle ends the drill. It is important to note that 

USA Football considers "Thud" to be a full-contact level and limits the time that 

coaches can run drills at this speed and intensity. Other organizationsincluding the Ivy League and other college programs- do not include "Thud" as 

full contact. 

Live action- Game-like conditions and the only time players are taken to the 

ground. 

Through innovations such as the Youth Practice Guidelines and Levels of Contact, coaches 

instruct their players through a series of USA Football-developed drills to build confidence and instill 

the proper fundamentals. Through a player progression development model, players learn the right 

stage at the right age, using the same terminology as they mature mentally, physical and emotionally. 

USA Football's Heads Up Tackling technique teaches young athletes to make contact with their 

shoulders in an ascending strike and rip their arms up through the ball-carrier, grabbing the backside 

of the jersey- thus keeping the head and eyes up through the process. Likewise, USA Football's 

Heads Up Blocking technique takes a player from stance to steps to contact, using their hands- not 

their helmets to drive opponents out of the way. Laying the basic foundations, Heads Up Tackling 

and Heads Up Blocking fundamentals can be used to teach every type of tackle and block that a 

player needs to learn. 

As Dr. jon Devine, president of the American Medical Society for Sports Medicine, said; "We 

endorsed USA Football's Heads Up Football program in 2014, and it continues to advance player 
60 


21158.039

safety and change behavior for the better. Young athletes are safer when their coaches are trained, 

proper fundamentals are taught and protocols in the best available science are put into motion. 

Creating a program like Heads Up Football takes leadership -leadership one would expect from a 

national governing body of sport." 

USA Football works every day to improve education, establish research and pave innovation 

toward creating a better, safer game for the young athletes who enjoy the fun, exercise and social 

benefits of an exceptional team sport. 

# # # 

9 
61 

Mr. MURPHY. Thank you. 

Now we’ll hear the testimony of Mr. Margarucci. You’re recognized for 5 minutes. 

STATEMENT OF KEVIN MARGARUCCI 

Mr. MARGARUCCI. Thank you, Chairman Murphy, Ranking Member DeGette, and distinguished members of the subcommittee. It’s 

a privilege to be here today on behalf of USA Hockey to discuss the 

issue of player safety. 

USA Hockey takes safety as a top priority and always has and 

has been one of the leaders in safety among youth sports entities. 

The safety starts with our leadership and goes on down to the rest 

of our organization, from our president, Jim Smith; our executive 

director, Dave Ogrean; our chief medical and safety officer, Dr. Michael Stuart, from the Mayo Clinic in Rochester, Minnesota; the 

chairman of our Safety and Protective Equipment Committee, Dr. 

Alan Ashare from the St. Elizabeth’s Medical Center in Boston. He 

chairs a committee that has been around for some 40 years, which 

guides our board in making safety policies for our sport. 

The USA Hockey Foundation yearly awards grants in the area 

of injury prevention and research with ice hockey injuries. Recently, I was hired as manager of player safety, a full-time position 

at USA Hockey, which further shows a commitment to safety in 

our sport. 

And, finally, we’ve had the Hockey Equipment and Certification 

Council, which was urged to be formed by USA Hockey in 1978. 

This is an independent body which studies the equipment that 

manufacturers produce and makes sure that meets the standards 

for protection in ice hockey. 

When we look at prevention, we start with our rules enforcement. We have a very strict officiating education program, which 

involves online modules for refs at every level, classroom work, and 

on-ice clinics. At every level, once officials are working, they are supervised, mentored, and given feedback, and shown videos of proper rule enforcement to make the game safer. 

We have implemented stricter penalties, with emphasis on 

boarding, charging, checking from behind, and head contact. In 

2009 and 2010, our rule book focused on the standards of play and 

emphasis on body checking. In 2011, our executive board ruled to 

make a rule change which increased the legal age of body checking 

in our sport from 12 and under level to the 14 and under level. 

This decision was based on a lot of scientific research, not only on 

player skill development, but also safety and injury risks between 

those age groups. 

In 2009, USA Hockey created the American Development Model. 

This model is an age-appropriate skill development and training 

based off of research of long-term athlete development. 

Our coaching education program has been a gold standard in 

youth sports for years. In 2011–2012, there became online required 

modules for our coaches, which include concussion awareness and 

recognition in all those modules for the age-appropriate levels. 

Within this structure, we’ve published a checking the right way 

for youth hockey, which is an age-appropriate progression of skills 

required to properly body check in the game of hockey. It starts 

62 

with skating, and is always focused on attitude, ethics, and respect 

for the sport and your opponents. It goes from skating, positioning 

and angling, stick checking, body contact, and then body checking. 

Heads Up, Don’t Duck was a program initiated by Dr. Ashare in 

1995. This was followed in 2010 by our Heads Up Hockey program. 

Both programs, the emphasis is playing the game with your head 

up, especially when coming in contact with the boards, goalposts, 

or opponents; keeping your heads out of taking and giving a body 

check; do not check from behind; and a library of skills and drills 

to teach these to our players. 

We educate our members constantly through information available on our Web site; electronic communications through newsletters to our parents, players, coaches, officials, which often have 

concussion awareness and education materials in them. USA Hockey will start publishing an electronic newsletter specific to safety 

in the fall of 2016. 

Currently, the Mayo Clinic sports medicine is doing research to 

identify objective testing to identify those athletes with potential 

concussion using blood biomarkers, sideline EEGs, and the KingDevick Test. And this study is funded by our USA Hockey Foundation. 

Finally, on the treatment side, we have a comprehensive concussion management program available to all of our associations, 

which is the minimum standard for any USA Hockey program to 

follow. And the biggest message in this is when in doubt, sit them 

out. 

Thank you for allowing me to speak here today on this important 

topic of player safety and concussions. 

[The prepared statement of Mr. Margarucci follows:] 

63 


21158.040

Introduction: 

Statement of Kevin Margarucci, Manager Player Safety of USA Hockey 

Before The House Committee on Energy and Commerce 

Subcommittee on Oversight and Investigations 

May 13, 2016 

Thank you Chairman Murphy, ranking member DeGette and distinguished members of the subcommittee. It is a privilege to be here with you today to discuss an issue that is the top priority every 

day at USA Hockey and that is the safety of our participants. USA Hockey has long been a leader in safety 

among youth sports entities. Safety in the area of concussion prevention, education and research is no 

different. USA Hockey has incorporated many resources and research studies to develop rule changes, 

create educational materials and focus on age-appropriate athlete development. All ofthese have 

athlete safety in mind and are preventative concussion measures in our sport. 

Body Checking Rule Change: 

In 2011, the age level for legal body checking in games was increased from the 12U age group to the 

14U age group. This decision was made based on multiple scientific research studies that concluded: 

Among 11-12 year-old ice hockey players, playing in a league in which body checking is permitted 

compared with playing in a league in which body checking is not permitted was associated with a 3-fold 

increased risk of all game-related injuries and the categories of concussion, severe injury, and severe 

concussion. 

It is also known that the 11- year-old brain is more easily concussed, takes longer to recover from a 

concussion, and is more susceptible to more serious long-term effects if they suffer a concussion. In 

addition it is also known that the 11-year-old brain has not fully developed the ability to anticipate while 

multitasking. The ability to anticipate being hit is 50% of avoiding injury. 

LISA Hockey • 1775 Bob Johnson Drive • Colorado Springs. CO 80906 • 719.576.8724 

USAHockey,com 
64 


21158.041

USA Hockey's Official Rules allows that any local governing body may prohibit body checking at any 

classification under Rule 604a. 

Playing Rules: 

Based on injury epidemiology we look at multiple factors: who's at risk, how do they get injured, and the 

severity of those injuries. Concussions in hockey are caused by hits to the head, unanticipated open ice 

collisions and illegal play. This information helps us create the standard of play in the game of hockey. 

More severe penalties have been put in place to decrease the likelihood of these occurrences to prevent 

injury including concussion. Specific penalties leading to concussion are head contact, checking from 

behind, boarding, and charging. All these infractions carry a penalty of the following nature: 

1. A minor plus a misconduct or a major plus a game misconduct 

2. A major plus a game misconduct shall be assessed when the opponent is injured due to the 

infraction 

3. A match penalty for attempt to injure or deliberate injury may also be assessed. 

The following is from the USA Hockey Official Rules: 

Standard o(Piav and Rule Emphasis- Body Checking 

Through the standard of rules enforcement, our game will continue to allow the opportunity for improved skill 

development and a more positive hockey environment for all participants. This initiative will result in greater 

emphasis on skating, puck possession and the proper use of the body to establish position and legally gain 

a competitive advantage. The goal of the enforcement standard is to create an environment that enhances player 

skill development by reducing intimidating infractions designed to punish the opponent. This standard is 

designed to improve the proper skill of legal body checking or contact at all levels of play and will not remove the 

physical component from the game. A hard body check or using body contact/position (Body Contact categories) 

to gain a competitive advantage over the opponent should not be penalized as long as it is performed within the 

rules. The focus of the body check should be to separate the opponent from the puck. 

The principles of this enforcement standard include the following: 

•The purpose of a body check is to separate the opponent from the puck. 

•Only the trunk (hips to shoulders) of the body shall be used to deliver a body check. 

USA Hockey • 1775 Bob Johnson Drive • Colorado Springs, CO 80906 • 719.576.8724 

USAHockey.com 
65 


21158.042

•The check must be delivered to the trunk (hips to shoulders) and directly from in front or the side of the 

opponent. 

•Players who use their physical skills and/or anticipation and have a positional advantage shall not lose that 

advantage provided they use their body to check the opponent within the rules. 

•Players will be held accountable for acts of an intimidating or dangerous nature. 

Enforcement Standard- These penalties are to be called with very strict enforcement. 

BODY CHECKING (Body Contact Categories) Rule 604 

A player cannot deliver a body check to any player while participating in a Body Contact category. 

Examples include: 

•Makes deliberate physical contact with an opponent with no effort to legally play the puck 

•Uses overt hip, shoulder or arm contact with the opponent to physically force them off the puck. 

•Physically impedes the progress of the opponent with hips, shoulders or torso without establishing legal body 

contact and having no intent of playing the puck. 

BOARDING, Rule 603 

A player cannot commit any infraction, including body checking, for the purpose of intimidation or punishment 

that causes their opponent to go violently or excessively into the boards. 

Examples include: 

•Accelerating through the check to a player who is in a vulnerable position off of the boards that causes them to 

go violently into the boards. 

•Driving an opponent excessively into the boards with no focus on or intent to play the puck. 

•Any other infraction (tripping, cross-checking, charging etc.) that causes the opponent to go violently and 

excessively into the boards. 

CHARGING, Rule 607 

A player cannot take more than two fast strides or travel an excessive distance to accelerate through a body check 

for the purpose of punishing the opponent. Examples include: 

•Running or jumping into the opponent to deliver a check. 

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•Accelerating through a check for the purpose of punishing the opponent. 

•Skating a great distance for the purpose of delivering a check with excessive force. 

CHECKING FROM BEHIND, Rule 608 

A player cannot deliver a body check to an opponent directly from behind, or diagonally from behind. The onus is 

on the player delivering the check to not hit from behind. Examples include: 

•Body checking or pushing an opponent from behind directly into the boards or goal frame or in open ice. 

HEAD CONTACT, Rule 620 

A player cannot contact an opponent in the head, face or neck, including with the stick or any part of the players 

body or equipment. The onus is on the player delivering the check, regardless as to size differential, to not make 

contact in the head/neck area of the opponent. Examples include: 

•A body check delivered with any part of the body that makes direct contact with the head or neck area. 

•The use of the forearm or hands to deliver a check to the head or neck area of the opponent. 

ROUGHING 

A player cannot use the hands, stick or extension of the arms to body check an opponent or deliver an avoidable 

body check to a player who is not in possession and control of the puck. Examples include: 

•Intentionally playing the body of an opponent who does not have possession and control of the puck. 

•Delivering an avoidable check to a player who has already relinquished control ofthe puck by a pass or shot. This 

is oftentimes referred to as "finishing" the check. 

•Any avoidable contact after the whistle shall be penalized strictly, including serum situations around the goal or 

along the boards. Officials are instructed to assess an additional penalty to those players acting as the aggressor 

or who instigates any contact after the whistle. 

All USA Hockey members must demonstrate awareness and support for the application, spirit and the respect of 

the rules in order for continued improvement in the game of hockey. At the same time, it is important to 

remember that: 

•A player is entitled to use proper body position and body contact in all age classifications in orderto gain a 

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competitive advantage. 

•Players are allowed to compete for body position using their strength and balance in front of the goal or along the 

boards. 

•In Body Checking categories, the focus of the body check must be to separate the opponent from the puck. 

The American Development Model (ADM) 

The ADM was initiated in 2009 by USA Hockey. The ADM is an age-appropriate athlete development 

model created for the sport of ice hockey based on research and principles in the field of Long Term 

Athlete Development (LTAD). This model incorporates age appropriate training and skill development 

for hockey players at all levels 8U, lOU, 12U, 14U 16U, and 18U. Each level builds upon the skills and 

concepts of the previous level to ensure that athletes are being taught the appropriate skills they need 

and the appropriate time in their development. These skills and concepts at each age level are tailored 

for in-season, off-season, on-ice and off-ice training. 

Coaching Education Program (CEP): 

USA Hockey's Coaching Education Program embeds the concept of the ADM into the online educational 

modules. These modules are required for all USA Hockey registered coaches and teach the age 

appropriate concepts and skill development. In addition to hockey skill development, each age 

appropriate module has concussion education and awareness training. This material is presented by our 

Chief Medical and Safety Officer, Dr. Michael Stuart. After viewing the video portion of the concussion 

module there is a quiz which must be passed before moving on to the next section. This material is 

further enhanced with the CEP's in person Levell-5 Coaching Clinics. 

Another significant educational resource for coaches that ties into injury prevention is the publication, 

"Checking the Right Way far Youth Hockey." The core oft his program is the gradual introduction of 

checking skills. In line with the ADM, the foundations of these skills are attitude, ethics and respect. 

Starting with the BU through lOU, players should learn and develop skills of: 1) positioning and angling 

2) stick checking and 3) body contact. 

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Body checking skills are phased in during the 12U level and progressed to the 14U-18U levels where they 

will play body checking hockey. This age-appropriate program is developed for on-ice skill acquisition as 

well as off-ice training. 

USA Hockey Concussion Education Materials: 

The following programs have been initiated by USA Hockey as important safety initiatives for prevention 

and education in the area of concussion. All material is accessible at USAHockey.com under safety: 

1. Heads Up, Don't Duck: 1995. This program was initiated to teach coaches, athletes and parents 

the importance of playing the game of hockey with your head up to reduce the incidence of 

head/neck injuries. 

2. Heads Up Hockey: 2010. This program expanded on the Heads Up, Don't Duck initiative and 

created a program guide with messaging including 1) the basic principles on how to give and 

take a body check while keeping your head out of it, 2) do not check from behind and 3) to 

always wear a properly fitted certified hockey helmet. The motto Heads Up, Don't Duck is at the 

forefront of the drills and educational materials included in this program. This program includes 

an educational section on identifying and managing a player with a suspected concussion. 

3. Resource Guide for Injury Management 2016: This guide is a resource in all of our coaching 

education modules to further the recognition and management for concussions 

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USA Hockey Concussion Management Program: 

Below is the minimum concussion protocol to be followed by all USA Hockey programs. 

2015 Concussion Management Program 

Michael Stuart MD 

Alan Asharc MD 

The standard of care for current medical practice and the law in most states requires that !!!!Y 

athlete with a suspected concussion is immediately removed from plav. 

• A concussion is a traumatic brain injury- there is no such thing as a minor brain injury. 

• A player does not have to be "knocked-out"" to have a concussion-less than 10% of 

players actually lose consciousness. 

• A concussion can result from a blow to head, neck or body. 

• Concussions often occur to players who don't have or just released the puck, from openice hits, unanticipated hits and illegal collisions. 

• The youth hockey player's brain is more susceptible to concussion. 

• In addition, the concussion in a young athlete may be harder to diagnosis, takes longer to 

recover, is more likely to have a recurrence and can be associated with serious long-term 

effects. 

• Treatment is individualized and it is impossible to predict when the athlete will be 

allowed to return to play- there is no standard timetable. 

A player with any symptoms or signs; disorientation; impaired memory, concentration, balance 

or recall has a concussion. 

Remember these steps: 

I. Remove immediately from play (training, practice or game) 

2. Inform the player's coach/parents 

3. Refer the athlete to a qualified health-care professional 

4. Initial treatment requires physical and cognitive rest 

5. The athlete begins a graded exertion and schoolwork protocol. 

6. Medical clearance is required for return to play 

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Diagnosis 

Players, coaches, parents and heath care providers should be able to recognize the symptoms and 

signs of a concussion: 

Symptoms 

Headache 

Nausea 

Poor balance 

Dizziness 

Double vision 

131urred vision 

Poor concentration 

Impaired memory 

Light Sensitivity 

Noise Sensitivity 

Sluggish 

Foggy 

Groggy 

Confusion 

Appears dazed or stunned 

Confused about assignment 

Moves clumsily 

Answers slowly 

Behavior or personality changes 

Unsure of score or opponent 

Can't recall events after the injury 

Can't recall events before the injury 

Management Protocol 

L If the player is unresponsive- call for help & dial9l I 

2, If the athlete is not breathing: start CPR 

./ DO NOT move the athlete 

./ DO NOT remove the helmet 

./ DO NOT rush the evaluation 

3, Assume a neck injury until proven othenvise 

./ DO NOT have the athlete sit up or skate off until you have determined: 

• no neck pain 

no pain, numbness or tingling 

no midline neck tenderness 

normal muscle strength 

normal sensation to light touch 

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4. If the athlete is conscious & responsive without S)mptoms or signs of a neck injury ... 

help the player off the ice to the locker room 

perform an evaluation 

do not leave them alone 

5. Evaluate the player in the locker room: 

Ask about concussion symptoms (How do you feel?) 

Examine for signs 

Verify orientation (What day is it?, What is the score?, Who are we playing?) 

Check immediate memory (Repeat a list of 5 words) 

• Test concentration (List the months in reverse order) 

Test balance (have the players stand on both legs, one leg and one foot in front of 

the other with their eyes closed for 20 seconds) 

Check delayed recall (repeat the previous 5 words after 5-10 minutes) 

6. A player with any symptoms or signs, disorientation, impaired memory, concentration, 

balance or recall has a concussion. 

''When in doubt, sit them out" 

Remove immediately from play (training, practice or game 

Inform the player's coach/parents 

Refer the athlete to a qualified health-care professional 

Medical clearance is required for return to play 

7. If any of the signs or symptoms listed below develop or worsen: go to the hospital emergency 

department or dial 911. 

~ Severe throbbing headache 

~ Dizziness or loss of coordination 

~ Memory loss or confusion 

~ Ringing in the cars (tinnitus) 

~ Blurred or double vision 

~ Unequal pupil size 

~ No pupil reaction to light 

~ Nausea and/or vomiting 

~ Slurred speech 

~ Convulsions or tremors 

~ Sleepiness or grogginess 

~ Clear fluid running from the nose and/or cars 

~ Numbness or paralysis (partial or complete) 

~ Difficulty in being aroused 

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8. An athlete who is symptomatic after a concussion initially requires physical and cognitive rest. 

A concussed athlete should not participate in physical activity, return to school, play video 

games or text message if he or she is having symptoms at rest. 

Concussion symptoms & signs evolve over time- the severity of the injury and 

estimated time to return to play are unpredictable, 

9, A qualified health care provider guides the athlete through a Functional Return to School/Play 

protocoL 

USA Hockey Post-Concussion Functional Return to School/Play Protocol 

This protocol should not be initiated until after the athlete has been released to participate in the 

functional return to play protocol by a qualified health care provider, lfsymptom.v worsen tluring a 

functional test, tire test should be stopped and the athlete monitored until symptoms resolve, No further 

functional testing should be performed that day, Functional testing may resume the following day at the 

previously asymptomatic level if the athlete remains asymptomatic. If symptoms do not resolve, 

appropriate medical attention should be obtained. 

After each phase of functional testing, the presence of post-concussive symptoms should be 

assessed and progression to the next phase of functional testing will require the absence of postconcussive symptoms. Each phase requires a minimum of l day before progressing to the next phase. 

Levell: Physical and cognitive rest. 

Level2: Light aerobic exercise such as walking or stationary cycling. No resistance training. 

May read 20·40% of normal volume. Limited TV, but No vldeo games. Partial school day as 

tolerated. 

Level3: Sport·specific exercises. No resistance training. May read 40-60% of normal volume. No video games. full 

school da as tolerated. 

LevelS: Full contact practice. Full school day. 

Video ames OK. 
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Additional Educational Material: 

USA Hockey sends out regular electronic newsletters to its members that periodically include 

information on concussion awareness and education. 

USA Hockey Magazine is a monthly publication mailed to USA Hockey members. It has provided 

information on numerous safety issues, including concussion recognition and prevention. 

USA Hockey is creating a safety newsletter that will be distributed to members (including 

players, parents, coaches, officials) focusing solely on issues related to safety, both on and off 

the ice. The first issue will be distributed this fall. 

Future Directions: 

USA Hockey is looking at expanding non-checking options for players that play in the body checking age 

groups, 

USA Hockey took part in a Youth Sport Safety Governing Bodies Meeting overt he last two years. This 

meeting was led by the Korey Stringer Institute. The end result of this meeting was to produce a 

consensus statement on best practices for safety in youth sports. Concussion was part of this discussion, 

This document can provide a youth association a blue print for implementing these practlces within 

their governing body's structure and guidelines. The title of this document is: "The lnter~Associotion Task 

Force for Youth Sports Emergency Health and Safety: Best Practices Recommendations" 

USA Hockey is piloting a program next season with a select group of our associations. This is an online 

software based health and safety platform. This will allow us to have a better look into the types of 

injuries, including concussion, which our athletes at different levels of play are reporting. The platform 

allows us to gather de-identified data to look at injury rates and trends to make more informed 

decisions in regards to rule changes etc, 

USA Hockey Research Efforts: 

The USA Hockey Foundation has awarded grants in the area of ice hockey injury research and 

prevention. The Mayo Clinic in Rochester, Minnesota is currently involved in concussion research made 

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possible through one of these grants. The study is looking into identifying objective measures to identify 

athletes who may have suffered a concussion by investigating blood biomarkers, sideline EEG results, 

and the utilization of the King Devick Test. 

USA Hockey has been a major sponsor for the Mayo Clinic Sports Medicine Center's lee Hockey Summit 

1/11: Action on Concussion (2010, 2013). There is a planned Ice flockey Summit Ill: Action on Concussion 

for the fall of 2017. 

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Introduction: 

Summary of Kevin Margarucci, Manager Player Safety of USA Hockey 

Before The House Committee on Energy and Commerce 

Subcommittee on Oversight and Investigations 

USA Hockey has been a leader in safety among youth sports entities and has always had safety as its top 

priority. 

Safety and Protective Equipment Committee: This committee began some 40 years ago and is 

chaired by Dr. Alan As hare from St. Elizabeth's Medical Center in Boston. 

Chief Medical and Safety Officer: Dr. Michael Stuart from the Mayo Clinic in Rochester, 

Minnesota. 

Created a Manager of Player Safety position and hired in 2015. 

USA Hockey Foundation commitment to funding research on injury prevention 

USA Hockey sponsorship of Ice Hockey Summit: Action on Concussion 

Prevention: 

USA Hockey playing rules enforcement 

USA Hockey Standard of Play and Rules Emphasis: Body Checking 

USA Hockey rule change to increase the age for legal body checking 

Coaching Education 

American Development Model 

Diagnosis: 

Coaching certification (mandatory to include concussion education) 

USA Hockey materials and resources for players, parents, coaches 

Mayo Clinic Research on finding objective testing for concussions 

Treatment: 

USA Hockey Concussion Management Program 

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Mr. MURPHY. Thank you, Mr. Margarucci. 

Mr. Stenersen, you’re recognized for 5 minutes. 

STATEMENT OF STEVE STENERSEN 

Mr. STENERSEN. Good morning, Chairman Murphy, Ranking 

Member DeGette, and distinguished members of the House Oversight and Investigations Subcommittee of the Energy and Commerce Committee. My name is Steve Stenersen and I serve as CEO 

of U.S. Lacrosse, the sports Maryland-based national governing 

body. 

Our nonprofit organization has proactively led and funded many 

sport-specific prevention and research initiatives that have resulted 

in a number of interventions in the areas of rules, equipment, and 

education. We also participate actively in the efforts of numerous 

national collaborations focused on reducing injury risk in youth 

sport, which I have referenced in my written testimony. 

Lacrosse is the oldest sport native to the North American continent. Native American play was first documented by Jesuit missionaries in the 1600s. Modern rules for lacrosse were first adopted 

in the late 19th century, but two distinctly different versions of the 

sport for men and women evolved in the first half of the 20th century. Lacrosse has experienced an unprecedented surge of popularity in recent years, in part due to the formation of U.S. Lacrosse 

as the sport’s first national governing body in 1998. 

U.S. Lacrosse established a Sports Science and Safety Committee 

when the organization was formed, and that committee is comprised of prominent medical and research professionals representing a variety of specialties, as well as representatives from 

a number of multisport organizations. We’ve been described as one 

of the most proactive sports organizations in the country relative 

to our commitment to injury prevention, and we were recognized 

for our efforts in that regard last May through the introduction of 

a congressional resolution, H.R. 267. 

Our Sports Science and Safety Committee prioritizes and oversees research initiatives, recommends interventions to the U.S. Lacrosse board of directors, and leads the development of educational 

initiatives intended to reduce injury risk and directed to coaches, 

officials, players, and their parents. My written testimony includes 

references to the published research and safety interventions U.S. 

Lacrosse has led. 

We also have invested significantly in the development and deployment of the sport’s first standardized coaching/officiating curricula. Unfortunately, public focus is too often directed at equipment interventions, which are less effective in preventing injury 

than assuring that players are properly taught and games are 

properly officiated. Among the biggest challenges we face is convincing youth leagues and State high school associations that requiring our standards for lacrosse-specific coach and official education is fundamental to a safer and more enjoyable playing experience. 

The prevention of lacrosse-related concussion has been a particular area of focus for U.S. Lacrosse, and we’ve committed considerable time and resources to concussion education, research, and 

prevention. The benefits of playing youth sports are well docuVerDate Mar 15 2010 14:08 Apr 25, 2017 Jkt 037690 PO 00000 Frm 00080 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X145CONCUSSIONSPENDING WAYNE
77 

mented. And while lacrosse is considered to be relatively safe compared to other sports and activities, serious injuries, such as concussions, occur. 

There is much we have learned about the nature of concussion 

in recent years, particularly the critical importance of recognizing 

symptoms and removing children from play until cleared by a medical professional trained in concussion management. We’ve also 

learned that no piece of protective equipment on the market today 

can prevent a concussion; that the mechanism of injury is different 

from sport to sport; and in the case of lacrosse, different in boys 

lacrosse than girls lacrosse. 

We’ve learned that the injury and its recovery can be a very different experience for girls than boys, which demands further focus 

and study. And we’ve learned that increased sport specialization at 

younger ages is increasing the number of injury exposures for 

young athletes and contributing to increases in overuse injuries on 

developing bodies. 

Perhaps most importantly, we’ve learned that the vast majority 

of children who experience a concussion can recover fully if their 

injury is recognized quickly and they receive proper care. 

Concussion remains a significant health concern in youth sports 

and it will remain a priority for U.S. Lacrosse. Accordingly, we’ll 

continue to invest in research that helps us learn more about the 

mechanism and frequency of the injury in both boys and girls lacrosse in order to advance educational, rule, and equipment interventions most effective in reducing injury risk. 

Thank you for the opportunity to share my thoughts on this important issue, as well as your efforts to increase the health and 

wellbeing of our Nation’s young athletes. 

[The prepared statement of Mr. Stenersen follows:] 

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US Lacrosse Testimony 

Concussions in Youth Sports: Evaluating Prevention and Research 

Oversight and Investigations Subcommittee of the United States House Committee on Energy & 

Commerce 

2123 Rayburn 

May 13,2016 

Good afternoon Chairman Murphy, Vice Chairman McKinley, Ranking member DeGette and 

distinguished Members of the House Oversight and Investigations Subcommittee of the Energy 

& Commerce Committee. My name is Steve Stenersen, and I serve as the Chief Executive 

Officer for US Lacrosse, the sport's Maryland-based national governing body. Thank you for the 

opportunity to appear before you, as both a parent of lacrosse players and on behalf of US 

Lacrosse, to share our efforts to address player safety within boys' and girls' lacrosse, 

particularly in the area of sport-related concussion. 

Our nonprofit organization has proactively led and funded many sport-specific injury 

prevention and research initiatives that have led to a number of recent interventions in the 

areas of rules, equipment and education. We also participate actively in the efforts of 

numerous national collaborations focused on reducing injury risk in youth sport, including the 

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American Orthopedic Society for Sports Medicine's STOP Sports Injuries campaign, the National 

Athletic Trainer's Association's Youth Sport Safety Alliance, and the United States Anti-Doping 

Agency's Supplement Safety Now initiative. I currently serve on the boards of the National 

Sport Concussion Coalition and PINK Concussions, and I have served as a member of the 

American College of Sports Medicine's Concussion Legislation Working Group, as well as the Ivy 

League Men's & Women's Lacrosse Committee on Concussion. US Lacrosse also collaborates 

regularly with the NCAA and NFHS on rule development and safety interventions in men's and 

women's lacrosse, and we continue to partner with the American Society of Testing & Materials 

and the National Operating Committee on Standards for Athletic Equipment to develop and 

refine lacrosse equipment standards. We collaborate with outstanding national and regional 

health organizations like the Centers for Disease Control & Prevention, MedStar Health and 

Fairfax County (VA) Public Schools to provide additional guidance and resources for our national 

membership. 

Lacrosse is the oldest sport native to the North American continent. Native American play was 

first documented by Jesuit missionaries in the 1600s, so the sport has long been an integral part 

of Native American culture. Modern rules for lacrosse were first adopted in the late 19th 

century, but two distinctly different versions of the sport for men and women evolved in the 

first half of the 20th century. Participation in both versions of lacrosse grew incrementally until 

the sport experienced an unprecedented surge of popularity over the last twenty years, in part 

due to the formation of US Lacrosse as the sport's first national governing body in 1998. Since 

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that time, lacrosse has become one of the fastest-growing sports in the country, and US 

Lacrosse has grown to represent and serve over 450,000 members within 68 regional chapters 

throughout the United States. 

While US Lacrosse operations have expanded significantly since the organization's inception, 

our commitment to lead and learn from lacrosse-specific research on the frequency and 

severity of injuries at every level of boys' and girls' lacrosse has always been a priority. We 

understand that effective stewardship of a sport requires empirical data on which to base 

effective safety interventions. 

That's why we established a Sports Science & Safety Committee as one of ten board 

committees within our organizational structure when US Lacrosse was formed 18 years ago. 

This committee, which is currently chaired by Dr. Margot Putukian, Princeton University's 

Director of Athletic Medicine, is comprised of prominent medical and research professionals 

representing a variety of specialties, as well as representatives from a number of multi-sport 

organizations. Accordingly, US Lacrosse has been recognized as one of the most proactive 

sports organizations in the country relative to our commitment to injury prevention. In fact, US 

Lacrosse was recognized last May for its efforts to lead the sport in the areas of safety and 

education through the introduction of a Congressional Resolution, H.R. 267. 

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The US Lacrosse Sports Science & Safety Committee prioritizes and oversees research 

initiatives, recommends interventions to the US Lacrosse Board of Directors and leads the 

development of educational initiatives intended to reduce injury risk and directed to coaches, 

officials, players and their parents. The committee also issues position statements on various 

issues related to lacrosse safety. 

The following represents a sampling of published research led by US Lacrosse and focused on 

player safety: 

Descriptive epidemiology of scholastic lacrosse injuries 

Head, face and eye injuries in scholastic and collegiate lacrosse 

Risks and mechanisms of severe injuries among youth, secondary school, collegiate 

and post-collegiate lacrosse players using insurance claims data 

Trends in high school lacrosse injuries 

Epidemiology of concussion in boys' and girls' high school lacrosse players 

Trends in sports-related concussion incidence at the high school level, 1998-2007 

Evaluation of the women's lacrosse protective eyewear mandate 

Epidemiology of lacrosse injuries among youth players 

Additionally, the following are among US Lacrosse led or supported initiatives focused on injury 

prevention and education: 

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Sponsorship of a bi-annual Lacrosse Sports Medicine Symposium 

Production of a lacrosse-specific concussion education video 

Development of an exercise program designed to reduce ACL injuries in lacrosse 

Development of women's lacrosse specific headgear performance standard 

Development of lacrosse-specific Concussion Management Plan Guidelines 

Enactment of playing rule changes that prohibit and more severely penalize body 

contact (boys) and stick checking (girls) at younger age levels 

Development of a Lacrosse Athlete Development Model based on the physical and 

cognitive development stages of children 

Development of single-age segmentation for boys' and girls' play 

It's also important to note that US Lacrosse has invested significantly in the development and 

deployment of the sport's first standardized coaching and officiating education curricula, 

including accessible on-line resources and hands-on clinic sessions, which have formally trained 

and certified thousands of coaches and officials throughout the country in recent years. There 

is no more effective intervention to increase player safety than to require that coaches be 

properly trained to teach the sport...and that officials be properly-trained to consistently 

enforce rules. Unfortunately, public focus is too often directed at equipment interventions, 

which are far less effective in preventing injury than assuring that players are properly taught 

and games are properly officiated. Sport-specific education and certification programs offered 

by the national governing bodies of each sport should be a required credential for coaches and 

officials at every level play but, unfortunately, many youth and high school organizations do not 

require them. Among the biggest challenges US Lacrosse faces is convincing youth leagues and 

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state high school associations that requiring our national standards for coach and official 

education is fundamental to a safer and more enjoyable playing experience. 

The prevention of lacrosse-related concussion has been a particular area of focus for US 

Lacrosse, we have committed as much or more time and resources to concussion education, 

research and prevention as any national amateur sports organization in the country, and the 

composition of our Sports Science & Safety Committee reflects that focus. Thankfully, our 

multi-faceted efforts appear to be making a difference. 

It is well-documented that the benefits of playing youth sports far outweigh the risk of injury, 

and while the sport of lacrosse is considered to be relatively safe compared to other sports and 

activities, serious injuries such as concussions occur. There is much have we have learned about 

the nature of concussion injuries in recent years- particularly the critical importance of 

recognizing concussion symptoms, and removing children suspected of receiving a concussion 

from play until cleared by a medical professional trained in concussion management. Landmark 

legislation such as the Lystedt Law has been instrumental to increased knowledge and 

awareness of this serious injury. Unfortunately, the inconsistency of similar laws and their 

enforcement from state to state has not optimized the intended impact of this legislative 

intervention. 

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We have also learned that no piece of protective equipment on the market today will prevent 

the biomechanics that trigger a concussion injury, that the mechanism of injury is different 

from sport to sport and, in the case of lacrosse, different in boys' lacrosse than girls' lacrosse. 

We have learned that the injury and its recovery can be a very different experience for girls 

than boys, which demands further focus and study. And, we have learned that increased sport 

specialization at younger ages is increasing the number of injury exposures to young athletes 

and contributing to increases in overuse injuries on developing bodies. Perhaps most 

importantly, we have learned that the vast majority of children who experience a concussion 

can recover fully if their injury is recognized quickly and they receive appropriate care. 

In recent years, the levels of sports-related concussion awareness and knowledge have been 

raised significantly thanks to greater leadership and collaboration among state and federal 

agencies, the allied health community, nonprofit leaders and youth-serving sports 

organizations, like US Lacrosse, that have embraced the responsibility to effectively balance the 

integrity of a particular sport with the safety of participants. 

Concussion remains a significant health concern in youth sports, and it will remain a priority for 

US Lacrosse. Accordingly, we will continue to invest in research that helps us learn more about 

the mechanism and frequency of the injury in both boys' and girls' lacrosse in order to advance 

educational, rule and equipment interventions that will be most effective in reducing the risk of 

the injury. 

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Again, thank you for the opportunity to share my thoughts on this important issue, as well as 

your efforts to increase the health and well-being of our nation's young athletes. I would be 

happy to answer any questions that you many have. 

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Appendix 

Compilation of Lacrosse Head and Other Injury Research (2002-2016) 

Prepared by US Lacrosse 

1) ILFWLA, Biomechanical Study of Crosse Design (L. Livingston), 2002 

2) Journal of Applied Biomechanics, Physical and Mechanical Properties of Various Field 

Lacrosse Balls, (J Crisco, E Drewniak, M Alvarez, 0 Spenciner) 2005, 

3) AJSM, Epidemiology of Lacrosse Injuries in high School- Aged Boys and Girls: A 3 Year 

Prospective Study (Hinton, Lincoln et. al), 2005. Published in the American Journal of Sports 

Medicine in 2005, the authors gathered data on girls' and boys' lacrosse injuries for 359,040 

high school and 28,318 summer camp athletic exposures using a lacrosse-specific computerized 

injury surveillance system. They found overall injury rates for boys' and girls' high school 

lacrosse were significantly lower than collegiate play. 

4) ASJM, Head, Face, and Eye Injuries in Scholastic and Collegiate Lacrosse: A 4-Year 

Prospective Study (Lincoln, Hinton et. al), 2007. This article was originally published online 

January 4, 2007 in the American Journal of Sports Medicine. The authors gathered data on 

507,000 girls' and boys' high school and 649,573 women's and men's college lacrosse athletic 

exposures using sport-specific injury surveillance systems over four seasons. They identified 

most common scenarios for head, face, and eye injuries. 

5) NCAA (ISS) Research for women's lacrosse, 2006-2007 

9 
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6) Descriptive Epidemiology of Collegiate Women's Lacrosse Injuries, Published in the 

Journal of Athletic Training in 2007, this partner report to the men's report cited above, reviews 

16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for women's 

lacrosse and identifies potential areas for injury prevention initiatives. 

7) Effectiveness of Women's Lacrosse Eyewear (Hinton et. al), 2008 

8) Catastrophic Sports Injury Research 1982-2009, (Mueller, Cantu), 2009 

9) ACSM Video Analysis poster, 2009 (Caswell, Lincoln, Almquist, Dunn and Hepburn) 

10) AAP, Clinical Report Sports Related Concussion in Children & Adolescents (M. Halstead 

and Walter), 2010 

11) ACSM and AJSM, Concussion Trends in High School Lacrosse -A prospective 11 year 

Study (Caswell, Lincoln, Almquist, Hinton and Norris) 2011 (published in ASJM 1/29/11) 

12) ACSM Abstract: Video Incident Analysis of Head Injuries in High School Girl's Lacrosse 

(Caswell, Lincoln, Almquist, Dunn), 2011 

13) AJSM, Video Incident Analysis of Head Injuries in High School Girls' Lacrosse (S. Caswell, 

A. Lincoln, J. Almquist, R. Dunn, and R. Hinton), 2013 

14) AJSM, Video Incident Analysis of Concussions in Boys' High School Lacrosse, (S. Caswell, 

A. Lincoln, J. Almquist, R. Dunn, and R. Hinton) 2013 

1S} Clinical Journal of Sport Medicine, Rate of Injury Among Youth Lacrosse Players, (A. 

Lincoln, M. Yeger-McKeever, W. Romani, L. Hepburn, R. Dunn, and R. Hinton) 2013 

10 
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16) Journal of Applied Biomechanics, Surrogate Headform Accelerations Associated with 

Stick Checks in Girls' Lacrosse (J. Crisco, L. Costa, R. Rich, J. Schwartz, and B. Wilcox) 2014 

17) Johns Hopkins University, Bloomberg School of Public Health, Grand Rounds Presenter, 

Youth Sports Through A Public Health Lens (A. Lincoln, B. Griffin) 2014 

18) Injury Epidemiology, The epidemiology of boys' youth lacrosse injuries in the 2015 

season (Z. Kerr, S Caswell, A Lincoln, A Djoko, T Dampier) 2016 

19) ASSM, Boys Lacrosse Tournament Game Injuries; Boston (L. Hepburn, A. Lincoln, S. 

Caswell, B. Griffin) 2016 

11 
89 

Mr. MURPHY. Thank you, Mr. Stenersen. 

Mr. O’Neil, you’re recognized for 5 minutes. 

STATEMENT OF TERRY O’NEIL 

Mr. O’NEIL. Mr. Chairman, thank you. 

Mr. MURPHY. Would you put your microphone on, please? Is it 

on? There should be a light. And just pull it as close to you as possible. 

Mr. O’NEIL. So, Mr. Chairman, we’d like to begin, if we may, 

with a sound bite, 30 seconds from Dr. Ann McKee, which follows 

on many comments heard earlier this morning. Dr. McKee is one 

of our colleagues. These were her comments 2 months ago during 

your roundtable. 

[Video shown.] 

Mr. O’NEIL. ‘‘Immediately,’’ Mr. Chairman, a word we heard this 

morning as well, and that’s our middle name: immediately. 

Let me begin by saying here’s where we started with our chase 

for immediate results. The National Football League, 32 teams, 

2,000 players, as you know, practicing for 5 months in regular and 

postseason. There were 271 total concussions in the NFL this last 

year, 271. Question: Not in the games, but in practice, how many 

concussions do you think on NFL practice fields last season? Answer: Eight, because they’ve learned how to practice. Those eight 

concussions in a universe of 271 represents 3 percent. 

So now the big question. What is that number in high school 

football, do you think? What percentage of high school football head 

trauma occurs on the practice field? Sixty to 75 percent. The worst, 

most shameful statistic in all of football, and this is the reason 

we’re in business. This is the reason why a number of Hall of 

Famers, at no appearance fee, chase around the country with us; 

among them Warren Moon, Anthony Munoz, Tony Dorsett, Mike 

Ditka, showing high school coaches on video how to practice with 

less contact. These men do this generously because they believe 

this is the future of football. 

So let’s quantify our recommendations. We’re going to show you 

how they practice in the pros. 

[Video shown.] 

Mr. O’NEIL. This is called full-speed-to-contact practice, which 

means they run the play full speed to get the timing, the pacing, 

the choreography of the play, but at the last moment, the moment 

of imminent contact, rather than tackle, they break away from 

each other. It’s football ballet, as you see it here. 

Here’s Dartmouth College. 

[Video shown.] 

Mr. O’NEIL. You’ll see a pass down the middle. A safety in practice here could light up this receiver with a perfectly legal hit, but 

it’s his teammate, so at the last minute, he veers away from it. 

He’ll save that tackle for Saturday. OK? 

In the NFL, Cleveland Browns, watch number 22 in white here. 

He’ll track this play full speed. Everybody stays on their feet, because only bad things happen when you go to the ground. He 

tracks the ball carrier, but at the moment when he might tackle, 

he stops and let’s the ball carrier continue. 48 in brown, lead block 

here, one of the most vicious hits in all of football. What’s he do, 

90 

48 in brown, he comes—he identifies the player to be blocked, he 

comes to him, sinks his hips and just lays his hands on him. And 

what about this defensive back in the shadow? Is he going to tackle 

on a Wednesday or a Thursday? No. He did everything to put himself in position except make the tackle. 

Seattle Seahawks, same thing. Are they going to tackle a teammate in the middle of the week or save it for Sunday? They save 

it for Sunday. 

Contrast that now with high school football. Here’s a high school 

scrimmage. A quarterback has four teammates with their hands on 

him. Are they going to hold him up, wrap him and hold him up, 

or take him to the ground? This has been a good practice exercise 

for everybody involved. We’ve learned a little something from it. 

Let’s go back to the quarterback. Did we take him to the ground 

or wrap him up and hold him? We took him to the ground and 

broke his wrist. Totally needless. 

At this same high school in Connecticut, a young man named 

Cody Gifford played, son of Frank and Kathy Lee Gifford. Frank 

was a colleague of mine at ABC Sports many years ago. Cody actually made the team at USC as a walk-on. You can’t believe how 

proud his father was. My son, Liam, also played at this same high 

school. He’s now a backup quarterback at Tufts. 

Frank Gifford and I used to talk about this frequently, and one 

day we sat and we put together the composite injuries in high 

school between our two sons, the concussions, the fractures, the 

knee ligaments. How many of those 10 major injuries do you think 

occurred in games and how many in practice? Two in games, eight 

in practice. Utter madness, Mr. Chairman. 

So what do we recommend to rectify the problem? We are the 

only organization of the five national organizations who operate in 

this space that’s committed to an immediate abolition of contact 

football below the age of 14 and ninth grade. We want to convert 

those leagues to flag. No contact until ninth grade. 

Once in high school, no full contact in spring, summer, and off 

season; 3 hours total in preseason; 30 minutes a week during the 

season. 

Mr. MURPHY. We’re going to have to wrap up so we can continue 

on. 

Mr. O’NEIL. How does this compare to the other major organizations operating in this space? National Federation of High Schools 

and USA Football, which operate in concert, allow three times as 

much contact as we do, Pop Warner four times as much contact as 

we recommend, and the NCAA six times as much as we recommend. 

[The prepared statement of Mr. O’Neil follows:] 

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Testimony of Terry O'Neil 

Founder/CEO, Practice Like Pros 

Subcommittee on Oversight and Investigations 

"Concussions in Youth Sports: 

Evaluating Prevention and Research" 

May 13,2016 

My name is Terry O'Neil, founder/CEO of Practice Like Pros. My first 

career was in network television at ABC, CBS and NBC. I produced 

telecasts of many NFL football games, including three Super Bowls, and 

was privileged to meet top coaches of that generation Tom Landry of the 

Dallas Cowboys, Bill Parcells of the New York Giants, Joe Gibbs of the 

Washington Redskins, Dick Vermeil of the Philadelphia Eagles, Mike Ditka 

of the Chicago Bears, Bill Walsh of the San Francisco 49ers. I spent a lot of 
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time on their practice fields, saw how they prepared for games with minimal 

risk to their players. 

In the late '90s, when Mike Ditka took the head coaching job at the New 

Orleans Saints, I went along. My otiice, overlooking the practice fields, 

offered a magnificent view of NFL football ballet-- skillful, efficient 

practice, rarely marred by injury. 

A few years later, after our family had returned to Connecticut, my oldest 

son became a high school football quarterback. On his third day of practice 

as a freshman, he threw a touchdown pass but fractured his right index 

finger on the helmet of an onrushing lineman. This would never have 

happened in the NFL or college football, where they practice with a 

five-yard restricted zone, known as a "halo", around the quarterback. 

When I asked one of Liam 's coaches about rules of engagement in practice, 

he said, "Every player, every day, every practice, every drill, is live, 

including the quarterback." I told the story to Dick Vermeil.. ... he exhaled 

deeply and said, "Wow." 
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Due to injury, Liam missed exactly half of the 40 high school games his 

team was scheduled to play. These injuries nearly cost him a chance to play 

college football. 

Frank Gifford, my former colleague at ABC Sports, lived in the same 

Connecticut town. His son, Cody, played football at the same high school a 

few years before Liam. Frank and I often commiserated. One day, we 

counted the combined major injuries suffered by Cody and Liam in high 

school football: 

• 5 concussions, 

• 4 orthopedic fractures, 

• l tom knee ligament. 

To our amazement, we realized that only two of these injuries bad occurred 

in games. The other eight were suffered in practice! 

So in 2013, I called a few players and coaches from my prior careers. Then 

l cold-called a few top names in medical science. Pretty soon, we had a 

squad to launch Practice Like Pros: Mike Ditka, Archie Manning, 

Ronnie Lott, Warren Moon, Anthony Munoz, Tony Dorsett, Rocky Seto, 
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Buddy Teevens, Dr. Robert Cantu, Dr. James Andrews, et a!. See the 

full list at~~~==="=--'==-'· 

We found that Cody's and Liam's experiences were not all that unusual. In 

high school football, a shocking 60% to 75% of head trauma occurs in 

practice. In the NFL, that number is 3%. (Sources: NFLPA, Concussion 

Legacy Foundation.) That 60% to 75% is the worst, most shameful statistic 

in football because coaches and administrators control the rules of 

engagement in practice. 

In the fonnative months ofPractice Like Pros, I met plenty of resistance. 

Then I connected with Steve Dembowski, the head coach at Swampscott 

(Ma.) High School, who told me, "Teny, we'd all like to practice with less 

contact; we just don't know how." 

Bingo! That became the immediate mission of Practice Like Pros--

showing high school coaches .... not telling them, showing them with video 

from the Cleveland Browns, Seattle Seahawks, Jacksonville Jaguars and 

Dartmouth College. 
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Our first video clinic was staged August 10, 2013, in Worcester, Ma. 

Today's hearing on Capitol Hill is our 30th appearance. Here's our 

scoreboard: In three years-plus since the founding of Practice Like Pros, 

44 of 50 states have voted to reduce contact on their high school football 

practice fields. 

But we have so much more to accomplish, beginning with the conversion of 

youth (age 5 to 13) play from contact football to flag. All available science, 

including two recent studies by Dr. Robert Stern, confirm the belief first 

expressed by Dr. Cantu that boys should not begin playing contact football 

until ninth grade. 

And once they enter high school football, they should: Practice Like Pros, 

i.e.: 

• no full-contact in spring/summer/off-season, 

• three hours full-contact total, including scrimmage(s), in pre-season, 

• 30 minutes full-contact per week in regular season. 

Our effort to implement these standards runs contrary to recommendations 

of four national governing bodies. For instance, in regular season, USA 
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Football and the National Federation of High Schools (NFHS) recommend 

three times the contact that we advocate, Pop Warner four times, and the 

NCAA six times. 

In addition, none of these organizations opposes full-contact in spring/ 

summer/off-season. Some states allow high school teams as much as 18 

days of full-contact in spring! That's like playing another half-season. 

Our pre-season and regular-season standards have been adopted by one state 

-Wisconsin- and the results have been superb. A study by the University 

of Wisconsin Medical School, published in October, 20 I 5, reports that 

Wisconsin high school football concussions have been reduced by more 

than half since adoption of the new restrictions (see attachment). 

At the college level, Dartmouth Coach Buddy Teevens, one of our leading 

supporters, has pioneered an outright ban on full-contact in practice. His 

team tackles only 10 times per year- on their I 0 game days. 

And in the NFL, progress has been undeniable since the revolutionary 2011 

collective bargaining agreement. Last season, of 271 total NFL 
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concussions, only eight were suffered on practice fields in regular- and 

post-season. 

So our template of limited-contact practice is available and thriving at all 

three levels. And again we emphasize: there should be no fourth 

level.. ... grade-school boys should play flag, not contact, football. 

The question now is how quickly we can affect change. We quote the 

words ofDr. Ann McKee, speaking to this Committee March 14: 

Respectfully submitted, 

Terry O'Neil 

FounderfCEO 

Practice Like Pros 

If there is something we can do to limit this risk, 

it must be done immediately. 

www. practicelikepros.com 
98 


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99 


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\\l 

WIAA Football Player on Player Contact 

Limitations are the following: 

Drill Contact (Ak, Bags and Wrap) is unlimited. Competition/Full Contact (Thud and live/Full) has limitations 

The Acclimatization Regulations also apply. 

Week 1-Only Drill Contact (Air, Bags and Wrap) is allowed and it is unlimited. Competition/Full Contact is 

not allowed. 

Week 2- Drill Contact (Air, Bags and Wrap) is unlimited. Competition/Full Contact (Thud and Live) is limited 

to 75 minutes per week (excluding a scrimmage). 

Week 3 and beyond Drill Contact (Air, Bags and Wrap) is unlimited. Competition/Full Contact (Thud and 

Live) is limited to 60 minutes per week (excluding games). 
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News and Events 

Concussion Rates 

footbaU 

Down After New Rule in 

Madison, W!sconsln ~ New research shows that 

football practices can have a big impact on rt\duclng 

team practkes. 

amount of fuiH:ontatl 

School 

Full contact Is defined as drills or game situations when full tackles are mm:le at a competitive puce and pla,·ers are 

taken to the ground. 

study was presented October 24 at the Am-erlcan Academy of Pediatrics nattonaJ -conference in Washington~ 

o.c. 

"This confirms what athletic trainers In high·school footb<ll! have lort9 believed about the association 

contact or practices and the likelihood McGuin<>. •This Is pmbably also true for other 

ftlotball Injuries stJch as sprains, lmctures and disloc•ti<ms." 

The study used data from the Wisconsin lnterscholastlc Research Network. which has recnrited and 

enrolled more than 16,000 adolescent athletes from ana sport venues across Wisconsin. Thilv 

serve <ls subJect'S for- cross~secth:m<:~!, cohort and rarrdoml;"'c:l contnJl trlals. 

The studv's lindlngs suggest that limitli1g full·rontact high school footooll practices may be a no·brainer, McGuine 

said. 

school coaches about 

students f\X>m head 

Date Put>Ush\!d: 10/26/2015 

the!. amount of fu!f :contact would be an effec:tlve and economica! way 

said. 
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Me O'NeiL 

l·~inlz, 

St No1bert (Qllege 

Good TtMy, 

Pleas,:> send me yow presentation from la~t night's WFCA convt'ntion. 

to show 1t to a!f our other waches, and sl,lfl redesignmy what we do for 

(oach Ryan Kars!f:n 

Siren High Sr:hoo!. Sire!\ V\li. 

Terry, 

Great at lhl? WFCA clinir thi~ past week.?nd -very much appre<:1<Hed' Please 

send me the Our staff is looking forward !o ttw tape! 

Skip Verick, !U3 

E:.!>! Trov 

Terry, 

Thank you an excellenl presentation 

I want lo '!Korporilte a lot it into ow 

Coach Bob Lichty 

University of Wisconsin· Lacrosse 

Mr. ()Nell 

Plt:d~': st:nd rnc-l vidz:o~ 

the 0· here at \JVI,LL;cro:>>c', 

Thanks for the presentation you and Coach T elevf'ns made l,;st night dt our state 

clinic·. It was incredibly valuable and eye opening. Phc.ase send the videos. 

Coach SroH Cramer. Defensive Coortimato; 

Verona Area H.S, Wildcat~. Verona, WI. 

Thank you Terry lt turned out 9reat Many positive comments on you dnd Buddy. 

Dan Bnmn<'f. Exo:>cutrve D1rect0r 

Wi~amsin 
102 

Mr. MURPHY. Thank you. And during questions, if there’s other 

conclusions you want to make, we’ll—we’re way over time. 

Dr. Comstock, you’re recognized for 5 minutes. 

STATEMENT OF R. DAWN COMSTOCK 

Dr. COMSTOCK. Thank you, Chairman Murphy. It’s an honor to 

be asked to testify before this committee, particularly representing 

Colorado’s School of Public Health at the University of Colorado 

Anschutz Medical Campus as a—under Congresswoman DeGette’s 

in her State. 

I’m here today because I run the National High School SportsRelated Injury Surveillance Study. I’ve done so for the last 11 

years. In effect, I’ve dedicated my entire career to trying to improve 

high school athletes’ safety, not because I’m a policymaker or a clinician, but because I collect the data that’s needed to drive informed, evidence-based decisions. I want to share just a few examples today and describe why those are so important. 

This first slide shows some high school RIO data, just simple 

concussion rates over time. You can see that concussion rates were 

stable for a few years before dramatically increasing, in fact, doubling between 2008 and 2012. They’ve leveled off in recent years. 

Understanding trends over time like this is crucially important 

both so that we can evaluate the magnitude of the problem, but 

also so that we can determine which interventions may, in fact, be 

effective and which ones may not. Only long-term surveillance information can provide this data. 

This next slide shows that some of the information I heard a little earlier that, you know, we don’t want to wait to try to do intervention work because we don’t want to wait for the years and years 

it takes to collect the data; we don’t have to wait. I intentionally 

put just 1 year worth of high school RIO data up here to show you 

that, even with 1 year of surveillance, we can look at patterns and 

trends across sports, across genders, across type of activity. And 

this is just the tip of the iceberg. 

I capture up to 300 variables on every concussion that’s reported 

to my system. I can literally tell you when, why, where, how, and 

to whom each concussion occurred. This data can drive evidencebased intervention efforts. 

And I and many other researchers in the United States have the 

drive, the desire, the resources, technological and methodological, 

and the experience to be able to do this work at the youth level, 

just as it’s currently being done at the collegiate and high school 

levels. What we don’t have is the funding. 

Injury surveillance can also demonstrate positive outcomes as 

well; very important. This slide shows that we’ve actually had a big 

success when it comes to managing high school athletes’ concussions. In the 2007–2008 academic year, 30 percent of high school 

athletes diagnosed with a concussion returned to play in less than 

7 days, which is a violation of accepted return-to-play guidelines. 

And disturbingly, 8 percent returned to play the same day they 

were injured. That’s unacceptable. 

Look at how things have improved. Last year in 2014–2015, less 

than 10 percent of all athletes returned to play within 6 days, and 

less than 2 percent returned the same day they were injured. This 

103 

is the result of prevention; not equipment prevention, but education and regulation prevention. Effective prevention in public 

health, we talk about three legs of a stool. Equipment is one piece 

in terms of concussion, but educating individuals and providing 

good, strong policy based on evidence are the other two legs. 

I would love to come away from the efforts of this committee, incredibly important efforts, with the ability to do this work at the 

youth level. Currently, no one can give you this type of data for 

children playing sports who are younger than high school age. 

That’s a travesty. We’ve got to protect our children who are playing 

sports because we want them to play sports. 

I’m not against sports, not even against contact sports. Despite 

my appearance, I played rugby for 13 years. Yes, I’m only 4’ 11’’. 

I played rugby for 13 years. I appreciate the fact that participating 

in sports is a very important way that children can incorporate 

physical activity as part of a daily, healthy lifestyle. 

We need everyone sitting at this table and our policy representatives, like the distinguished members of this panel, to work together to drive evidence-based prevention practices now. We don’t 

want to wait for 30 years to learn about long-term consequences of 

concussion. That’s secondary and tertiary prevention. We need primary prevention. I already know that concussions are bad for us. 

I want to keep kids from being injured in the first place. 

Thank you. 

[The prepared statement of Dr. Comstock follows:] 

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Summary of Testimony of Dr. R. Dawn Comstock for the U.S. House of 

Representatives' Committee on Energy and Commerce, Subcommittee on 

Oversight and Investigations hearing entitled "Concussions in Youth Sports: 

Evaluating Prevention and Research." Friday, May 13, 2016 

1) There have been vast improvements in our knowledge of youth sportsrelated concussions over the past decade. 

2) Sports are an important way for children to incorporate physical activity into 

a healthy lifestyle and parents should not be afraid to allow their children to 

play sports but it is imperative to make concussion prevention specifically 

and athlete health and safety in general a priority. 

3) To date the majority of federally funded concussion work has focused on 

improving concussion diagnosis, improving management of concussed 

athletes, and improving our understanding of the long term negative health 

outcomes associated with concussion -all of which arc important, but none 

of which reflect primary prevention efforts. It is time to shift the focus to 

primary prevention. 

4) Effective concussion prevention efforts will need to be sport-specific, 

targeted, evidence-based, and multi-faceted. 

5} We do not currently have any national sports injury surveillance programs 

capable of providing the information required to drive such prevention 

efforts for athletes younger than high school aged. 
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Testimony of Dr. R. Dawn Comstock for the U.S. House of Representatives' 

Committee on Energy and Commerce, Subcommittee on Oversight and 

Investigations hearing entitled "Concussions in Youth Sports: Evaluating 

Prevention and Research." Friday, May 13, 2016 

Chairman Murphy I am honored to testify on the important topic of youth 

sports-related concussions before the Committee on Energy and Commerce's 

Subcommittee on Oversight and Investigations today. It is with pride that I 

represent the Colorado School of Public Health as a constituent of the ranking 

member ofthe committee, Congresswoman DeGette. 

As the Director of The National High School Sports-Related Injury 

Surveillance Study, more commonly (and more easily) referred to as High School 

RIO, I have spent my entire career attempting to improve young athletes' health by 

providing the evidence needed to make sports as safe as possible (see Appendix 1). 

I was asked to attend to day's hearing to share the current state of research in the 

area of youth sports-related concussion. First l must note how much has improved 

over the past decade. When I established High School RIO in 2005 concussions were 

not yet resonating as a concern among parents of young athletes. Injured athletes 

were frequently said to have had their "bell rung" or to have been "dinged" and 

sports-related injuries, including concussions, were considered by most parents to 

be unavoidable, "just part of the game," or "the price you have to pay to play." Much 

has changed. Massive media attention, state level legislative efforts, and educational 

efforts by numerous organizations occurred concurrently with, and in fact were at 
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times driven by, great advancements in our understanding of the rates and patterns 

of concussion among high school athletes. I'll highlight a few advancements in our 

knowledge using examples from my High School RIO dataset. 

1) Ongoing surveillance efforts have demonstrated a rapid increase in 

concussion rates over the past decade (see Appendix 2). Most believe this 

increase reflects better diagnosis and capture of concussion injuries rather 

than a true increase in the numbers of concussions. Encouragingly, 

surveillance data from the past few years demonstrates concussion rates 

have leveled off. However, continued surveillance is needed to monitor these 

ongoing trends. 

2) Concussion rates vary by sport, gender, and type of athletic activity (see 

appendix 3). For example, first in terms of sport-specific differences, football 

has the highest rates of concussion in both competition and practice with 

other full contact sports (boys' ice hockey and lacrosse) also among the four 

sports with the highest rates. Many are surprised to Jearn girls' soccer has 

consistently had competition concussion rates as high as or higher than these 

boys' sports. However, practice is a different story. Cheerleading, which has 

a low competition/performance concussion rate relative to other sports has 

the second highest practice concussion rate. Conversely, boys' ice hockey has 

a low practice concussion rate relative to other sports. Second, in gender 

comparable sports girls have significantly higher concussion rates than boys. 

Finally, in nearly every sport, competition concussion rates are significantly 

higher than practice concussion rates. Understanding such differences is 
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essential as it demonstrates that concussion prevention efforts can't be "one 

size fits all." Rather effective, targeted prevention efforts must be evidencebased and sport-specific. 

3) Improvements have been made in management of concussed athletes (see 

appendix 4). In 2007/08, over 30% of high school athletes diagnosed with a 

concussion returned to play within a week of their injury which is premature 

according to accepted return to play guidelines and, disturbingly, 8% were 

allowed to return to play the day they were injured. Following massive 

educational efforts by the National Federation of State High School Athletic 

Associations (NFHS), the Centers for Disease Control and Prevention's 

National Center for Injury Prevention and Control, and others we have 

observed very positive trends. Last academic year (2014/15) less than 10% 

of high school athletes diagnosed with a concussion returned to play within a 

week of their injury and less than 2% returned to play the day they were 

injured. These are encouraging trends indications the parents, coaches, and 

clinicians of young athletes are now all much more aware of the signs and 

symptoms of concussion, the importance of removing an injured athlete from 

play, and the need for an injured athlete to be kept out of play until released 

to return by an appropriate health care advisor. 

At this point I feel it is important to note that I am not against sports, even 

contact sports. I don't want parents to be afraid to allow their children to play 

sports. We have an epidemic of obesity in our country and playing sports is a great 

way for our youth to incorporate daily physical activity into a healthy lifestyle. 
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Despite our current concern over concussions, the negative effects of an inactive 

lifestyle (e.g., diabetes, heart disease, etc.) are more concerning due to their 

relatively high likelihood compared to the very small likelihood that any individual 

child will sustain a serious sports-related injury resulting in life-long problems. 

Additionally, while you may have difficulty envisioning this looking at the middle 

aged, 4'11", slightly overweight woman sitting before you, I was a three-sport 

athlete at Centennial High School in Pueblo Colorado and as an undergraduate at 

Colorado State University I began playing rugby, a sport I pursued for 13 years. I 

learned about work ethic, teamwork, commitment, etc. from playing sports and 

because of my time playing rugby I recognize the sense of accomplishment and 

adrenalin rush one gets when you make a good tackle and I appreciate the life 

lessons embodied in picking yourself up and returning to play after being tackled. 

understand that the culture of full contact sports must be respected if we are to 

make any progress toward concussion prevention. However the time has come and 

past for the adults involved in youth sports- the parents, coaches, administrators, 

educators, researchers, clinicians, policy makers, and regulators -to recognize that 

keeping young athletes as safe as possible must be made a priority and will only be 

effective if approached as a team effort. 

With this in mind, I want to extend particular thanks to this committee for 

holding a hearing focused on prevention. When I was asked to present a 

researcher's view of the current state of concussion prevention I realized the 

importance of briefly noting the differences between primary, secondary, and 

tertiary prevention. Primary prevention is literally preventing a negative health 
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event, such as an illness or injury, from occurring in the first place while secondary 

and tertiary prevention encompass minimizing the clinical impact and life long 

effects of a negative health event after it occurs. This is pertinent to today's hearing 

because, to date the vast majority of federally funded concussion research has 

focused on improving concussion diagnosis, improving concussion management, 

and improving our understanding of the long-term effects of concussion (e.g., CTE). 

While each are incredibly important endeavors, they are clearly associated with 

secondary or tertiary prevention, having very little to nothing to do with primary 

prevention. I believe we should be spending much more effort working to prevent 

our young athletes from being injured in the first place. 

To that end, I was also quite pleased to learn that to day's hearing would be 

focused on prevention efforts other than equipment. Simply stated, there is no such 

thing as a perfect piece of protective equipment- for example, no helmet will ever 

be able to prevent all concussions. Unfortunately aggressive marketing and our 

tendency to look for quick and easy fixes has led far too many parents to put far too 

much faith in the unsubstantiated concussion prevention claims of far too many 

manufacturers. While it is important to ensure the effectiveness of protective 

equipment is not oversold, it is even more important for us to realize that protective 

equipment will always only be only one piece of the concussion prevention puzzle. 

In public health we speak of the "three-legged stool of prevention"- the concept 

that the most effective prevention efforts are multi-faceted. The three legs of the 

prevention stool are engineering, education, and regulation. Our roadways are safer 

today despite the ever-increasing density of motor vehicle traffic because we have 
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effectively combined engineering (e.g., air bags, anti-lock breaks, etc.), education 

(drivers education classes, don't text and drive advertising campaigns, etc.), and 

regulation (speed limits, drunk driving laws, etc.). Effective sports-related 

concussion prevention efforts will likewise require a multi-faceted approach. While 

efforts to improve protective equipment is one "leg ofthe stool" this must be 

accompanied by educational efforts (e.g., the National Federation of High School 

Athletic Associations' [NFHS] recent recommendations regarding limiting the 

number of days a week football coaches incorporate full contact activities in practice 

sessions, the Center for Disease Control and Prevention's National Center for Injury 

Control and Prevention's "Heads Up" concussion toolkits for coaches, etc.) and 

regulatory efforts (e.g., Pop Warner's elimination of kickoffs in their youngest age 

groups, better enforcement of the existing soccer rules to reduce player-player 

contact, etc.). These multi-faceted concussion prevention efforts must be evidencebased and sport specific- the stool is only stable if all three legs are strong. 

However, in order to develop evidence-based, sport specific interventions we 

need better information. While evidence of the association between single or 

repeated blows to the head sustained during sports activity and brain injury was 

published in the medical literature as early as 1928, in its 2013 report on youth 

sports related concussions the Institute of Medicine noted that "The National 

Collegiate Athletic Association Injury Surveillance System and High School RIOTM 

(Reporting Information Online) data system are the only ongoing, comprehensive 

sources of sports-related injury data, including data on concussions, in young 

athletes." As the IOM report pointed out there is no national data collection tool 
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capturing equivalent sports injury information on athletes younger than high school 

age or high school aged children participating in sports outside of the school setting 

(e.g., recreational leagues, summer leagues, travel teams, all-star tournaments, 

summer camps, etc.). This literally means that no one is currently capable of 

providing reliable data on concussion incidence, rates, or patterns among the many 

millions of U.S. children younger than high school age or high school aged athletes 

playing outside the school setting. This is simply unacceptable because the 

importance of such information is undeniable and the knowledge, experienced 

personnel, and technicaljmethodological resources to obtain such information 

exists -the only thing which is lacking is adequate funding. 

The NCAA and NFHS have provided a roadmap for all youth sports 

organizations. Those two institutions made the commitment to improve athlete 

health and safety by utilizing injury surveillance data in informed discussions 

leading to evidence-based decisions. I hope the work of this committee will 

somehow result in some source of federal support for an equivalent surveillance 

program for injuries sustained by our youngest athletes which could then be used 

by the numerous sports governing bodies overseeing youth sports. If federal 

funding is not a possibility, perhaps it is time to acknowledge that youth sports have 

become big business and to demand that national governing organizations utilize 

some of their profits to establish their own injury surveillance systems. Knowledge 

is power- in this case the knowledge gained from surveillance data can power 

efforts to keep young athletes safe and healthy. 
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Appendix 1: Peer-Reviewed Scientific Publications Reporting Data from The 

National High School Sports-Related Injury Surveillance Study (High School 

RIOTM). Note: Concussion publications are balded and student/trainee 

authors are italicized. 

Of the 71 scientific papers reporting findings from analysis ofthe High School RIOTM 

dataset that have been published to date or currently in print, 17 (24%} have 

focused solely on concussions. 

1. Bryan MA, Rowhani-Rahbar A, Comstock RD, and Rivara FP. Sports· and 

Recreation-Related Concussions in United States Youth. Forthcomming, 

Pediatrics. 

2. johnson Band Comstock RD. Epidemiology of Chest, Rib, Thoracic Spine and 

Abdomen Injuries Among United States High School Athletes, 2005/05-

2013/14. Forthcomming, Clinical journal of Sports Medicine. 

3. Currie DW, Comstock RD, Fields SK, and Cantu RC. A Paired Comparison 

oflnitial and Recurrent Concussions Sustained by US High School 

Athletes within a Single Athletic Season. E-pub ahead ofprint,fournal of 

Head Trauma Rehabilitation. Published online May, 2016. DOl: 

10.1097 /HTR.0000000000000240. 

4. Tirabassij, Brou L, Khodaee M, Lefort R, Fields SK, and Comstock RD. 

Epidemiology of High School Sports-Related Injuries Resulting in Medical 

Disqualification: 2005-2006 Through 2013-2014 Academic Years. E-pub 

ahead of print, American journal of Sports Medicine. Published online May 10, 

2016. DOl: 10.1177/0363546544604. 

5. Collins CL, McKenzie LB, Ferketich AK, Andridge R, Xiang H, and 

Comstock RD. Concussion Characteristics in High School Football by 

Helmet Age/Recondition Status, Manufacturer, and Model: 2008/09 

Through 2012/13 Academic Years in the United States. E-pub ahead of 

print, American Journal of Sports Medicine. Published online Feb 23, 

2016. PMID: 26905506. 

6. Pierpoint LA, Williams CM, Fields SK, and Comstock RD. Epidemiology of 

Injuries in US High School Track and Field, 2008-2009 through 2013-2014. Epub ahead ofprint,American]ournal ofSports Medicine. Published online Feb 

26, 2016. PMJD: 26920435. 
113 


21158.084

7. Collins CL, McKenzie LB, Ferketich AK, Andridge R, Xiang H, and Comstock RD. 

Dental Injuries Sustained by High School Athletes in the United States, from 

2008/09 through 2012/13 Academic Years. E-pub ahead of print, Dental 

Traumatology. Published online Sept 26, 2015. PM!D: 26408377. 

8. Ashack KA, Burton KA, johnson TR, Currie OW, Comstock RD, and Dellavalle 

RP. Skin Infections Among US High School Athletes: A National Survey. E-pub 

ahead of print, journal of the American Acadamy of Dermatology. Published 

online Feb 2, 2016. PMID: 26850656. 

9. Mitchell ), Graham W, Best TM, Collins CL, Currie DW, Comstock RD, and 

Flanigan DC. Epidemiology of Meniscal Injuries in US High School Athletes 

Between 2007 and 2013. Knee Surgery, Sports Traumatology, Arthroscopy, 

24(3):715-722 (2016). 

10. Currie DW, Fields SK, Patterson MJ, and Comstock RD. Cheerleading Injuries 

in United States High Schools. Pediatrics, 137(1):1-9 (2016). 

11. Dizdarevic I. Low S, Currie DW, Comstock RD, Hammoud S, and Atanda A. 

Epidemiology of Elbow Dislocation in High School Athletes. American journal 

of Sports Medicine, 44(1):202-208 (2016). 

12. Reeser )C, Gregory A, Berg RL, and Comstock RD. A Comparison of Women's 

Collegiate and Girls' High School Volleyball Injury Data Collected 

Prospectively Over a Four-Year Period. Sport Health, 7(6):504-510 (2015). 

13. Kriz PK, Zurakowski RD, Almquist JL, Reynolds), Ruggieri D, Collins CL, 

d'Hemecourt PA, and Comstock RD. Eye Protection and Risk Risk of Eye 

Injuries in High School Field Hockey. Pediatrics, 136(3):521-527 (2015). 

14. Comstock RD, Currie DW, Pierpoint LA, Gruben hoff ]A, and Fields SK. An 

Evidence-Based Discussion of Heading and Concussions in High School 

Soccer. ]AMA Pediatrics, 169(9):830-837 (2015). 

15. Roos KG, Marshall SW, Kerr ZY, Golightly YM, Kucera KL, Myers )B, Rosamond 

WD, and Comstock RD. Epidemiology of Overuse Injuries in College and High 

School Athlehtes in the United States. American journal of Sports Medicine, 

43(7):1790-1797 (2015). 

16. Mitchell j, Magnussen RA, Collins CL, Currie DW, Best TM, Comstock RD, and 

Flanigan DC. Epidemiology of Patellofemoral Instability Injuries among High 

School Athletes in the United States. American journal of Sports Medicine, 

43(7):1676-1682 (2015). 

17. Monfort SM, Comstock RD, Collins CL, Onate )A, Best TM, and Chaudhari AM. 

Association between Ball-Handling versus Defending Actions and Acute 

Noncontact Lower Extremity Injuries in High School Basketball and Soccer. 

American journal of Sports Medicine, 43( 4):802-807 (2015). 

18. Matic GT, Sommerfeldt MF, Best TM, Collins CL, Comstock RD and Flanigan DC. 

Ice Hockey Injuries Among United States High School Athletes from 
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2008/2009-2012/2013. The Physician and Sportsmedicine, 43(2):119-125 

(2015). 

19. Schroeder AN, Comstock RD, Collins CL, Everhart), Flanigan D, and Best TM. 

Epidemiology of Overuse Injuries Among High-School Athletes in the United 

States. The journal of Pediatrics, 166(3): 600-606 (2015). 

20. Changstrom BG, Brou L, Khodaee M, Braund C, and Comstock RD. 

Epidemiology of Stress Fracture Injuries Among U.S. High School Athletes, 

2005-06 through 2012-13. American journal ofSports Medicine, 43(1):26-33 

(2015). 

21. Kerr ZY, Collins CL, Mihalik JP, Marshall SW, Guskiewicz KM, and 

Comstock RD. Impact Locations and Concussion Outcomes in High 

School Football Player-to-Player Collisions. Pediatrics, 134(3):489-496 

(2014). 

22. Collins CL, Fletcher EN, Fields SK, Kluchurosky L, Rohrkemper MK, 

Comstock RD, and Cantu RC. Neck Strength: A Protective Factor 

Reducing Risk for Concussion in High School Sports. journal of Primary 

Prevention, 35(5):309-319 (2014). 

23. Xiang j, Collins CL, Liu D, McKenzie LB, and Comstock RD. Lacrosse Injuries 

Among High School Boys and Girls in the United States, 2008-2012, Four 

Academic Years. American journal of Sports Medicine, 42(9):2082-2088 

(2014). 

24. Fletcher EN, McKenzie LB, and Comstock RD. Epidemiological Comparison of 

High School Basketball Injuries Reporting to Emergency Departments and the 

Athletic Training Setting. journal of Athletic Training, 49(3):381-388 (2014). 

25. Rosenthal ]A, Foraker RE, Collins CL, and Comstock RD. National High 

School Athlete Concussion Rates From 2005-2006 to 2011-2012. 

American journal of Sports Medicine, 42(7):1710-1715 (2014). 

26. Robinson TW, Corlette ), Collins CL, and Comstock RD. Shoulder Injuries 

Among US High School Athletes, 2005/2006-2011/2012. Pediatrics, 

133(2):272-279 (2014). 

27.joseph AM, Collins CL, Henke NM, Yard EE, Fields SK, and Comstock RD. A 

Multisport Epidemiologic Comparison of Anterior Cruciate Ligament Injuries 

in High School Athletics. journal of Athletic Training, 48(6):810-817 (2013). 

28. Smith DW, Myer GD, Currie DW, Comstock RD, Clark JF, and Bailes JE. 

Altitude Modulates Concussion Incidence: Implications for Optimizing 

Brain Compliance to Prevent Injury in Athletes. Orthopaedic journal of 

Sports Medicine, 1(6):1-7(2013). 

29. Swenson DM, Collins CL, Fields SK, and Comstock RD. Epidemiology of US High 

School Sports-Related Ligamentous Ankle Injuries 2005/06-2010/11. Clinical 

journal of Sports Medicine, 23(3):190-196 (2013). 
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21158.086

30. Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, and Comstock RD. 

Epidemiology of Knee Injuries Among US High School Atheltes, 2005/06-

2010/11. Medicine & Science in Sports & Exercise, 45(3):462-469 (2013). 

31. Badgeley MA, Mcilvain NM, YardE, Fields S, and Comstock RD. Epidemiology 

of 10,000 High School Football injuries: Patterns of Injury by Position Played. 

journal of Physical Activity & Health, 10(2);160-169 (2013). 

32. Chrisman SP, Rivara FP, SchiffMA, Zhou C, and Comstock RD. Risk 

Factors for Concussive Symptoms of 1 Week or Longer in High School 

Athletes. Brain Injury, 27(1);1-9 (2013). 

33. Kerr ZY, Casa OJ, Marshall SW, and Comstock RD. Epidemiology of Exertional 

Heat Illness Among U.S. High School Athletes. American journal of Preventive 

Medicine, 44(1);8-14 (2013). 

34. Kriz PK, Comstock RD, Zurakowski RD, Almquist JL, Collins CL and 

D'Hemecourt P. Effectiveness of Protective Eyeware in Reducing Eye Injuries 

Among High School Field Hockey Players. Pediatrics, 130(6);1069-1075 

(2012). 

35. Swenson DM, Henke NM, Collins CL, Fields SK, and Comstock RD. 

Epidemiology of United States High School Sports-Related Fractures, 2008-09 

to 2010-11. American journal of Sports Medicine, 40(9);2078-2084 (2012). 

36. Castile L, Collins CL, Mcilvain NM, and Comstock RD. The Epidemiology of 

New vs. Recurrent Sports Concussions Among High School Athletes, 

2005-2010. British journal of Sports Medicine, 46(8);603-610 (2012). 

37. Marar M, Mcilvain NM, Fields SK, and Comstock RD. Epidemiology of 

Concussions among United States High School Athletes in 20 Sports. 

American journal of Sports Medicine, 40(4);747-755 (2012). 

38. Meehan WP, d'Hemecourt P, Collins CL, Taylor AM, and Comstock RD. 

Computerized Neurocognitive Testing for the Management of SportRelated Concussions. Pediatrics, 129(1);1-7 (2012). 

39. Meehan WP, d'Hemecourt P, Collins CL, and Comstock RD. Assessment 

and Management of Sport-Related Concussions in United States High 

Schools. American journal of Sports Medicine, 39(11);2304-2310 (2011). 

40. Rechel ]A, Collins CL, and Comstock RD. Epidemiology of Injuries Requiring 

Surgery among High School Athletes in the United States, 2005 to 2010. 

journal of Trauma, 71( 4);982-989 (2011). 

41. Kerr ZY, Collins CL, Fields SK, and Comstock RD. Epidemiology of PlayerPlayer Contact Injuries among US High School Athletes, 2005-2009. Clinical 

Pediatrics, 50(7);594-603 (2011). 

42. Kerr ZY, Collins CL, Pommering TL, Fields SK, and Comstock RD. 

Dislocation/Separation Injuries among US High School Athletes in 9 Selected 

Sports: 2005-2009. Clinical journal ofSports Medicine, 21(2); 101-108 (2011). 
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43. Yard EE and Comstock RD. Injury Patterns by Body Mass Index in US High 

School Athletes. journal of Physical Activity & Health, 8(2); 182-191 (2011). 

44. Frommer Lj, Gurka KK, Cross KM, Ingersoll, CD, Comstock RD, and Saliba 

SA. Sex Differences in Concussion Symptoms of High School Athletes. 

journal of Athletic Training, 46(1);76-84 {2011). 

45. Gilchrist J, Haileyesus T, Murphy M, Comstock RD, Collins C, Mcilvain N, and 

Yard E. Heat Illness Among High School Athletes- United States, 2005-2009. 

jAMA 305(3);246-249 (2011)- UAMA reprint of MMWR) 

46. Yard EE, Gilchrist J, Haileyesus T, Murphy M, Collins C, Mcilvain N, and 

Comstock RD. Special Report from the CDC: Heat Illness among High School 

Athletes- United States, 2005-2009. journal of Safety Research, 41;471-474 

(2010). 

47. Meehan WP, d'Hemecourt P, and Comstock RD. High School Concussions 

in the 2008-2009 Academic Year: Mechanism, Symptoms, and 

Management. American journal of Sports Medicine, 38(12);2405-2409 

(2010). 

48. Gilchrist), Haileyesus T, Murphy M, Comstock RD, Collins C, Mcilvain N, and 

Yard E. Heat Illness Among High School Athletes- United States, 2005-2009. 

Morbidity and Mortality Week(y Review (MMWR) 59(32);1009-1013 (2010). 

49. Swenson DM, Yard EE, Collins CL, Fields SK, and Comstock RD. Epidemiology 

of US High School Sports-Related Fractures, 2005-2009. Clinical journal of 

Sports Medicine 20( 4);293-299 (2010). 

50. Krajnik S, Fogarty KJ, Yard EE, and Comstock RD. Shoulder Injuries in US High 

School Baseball and Softball Athletes, 2005-2008. Pediatrics 125(3);497-501 

(2010). 

51. Yard EE, Collins CL, and Comstock RD. A Comparison of High School Sports 

Injury Surveillance Data Reporting by Certified Athletic Trainers and Coaches. 

journal of Athletic Training 44(6);645-652 (2009). 

52. Darrow C], Collins CL, Yard EE, and Comstock RD. Epidemiology of Severe 

Injuries among United States High School Athletes: 2005-2007. American 

journal of Sports Medicine 37(9);1798-1805 (2009). 

53. Yard EE and Comstock RD. Compliance with Return to Play Guidelines 

Following Concussion in US High School Athletes, 2005-2008. Brain 

Injury 23{11);888-898 (2009). 

54. Swenson DM, Yard EE, Fields SK, and Comstock RD. Patterns of Recurrent 

Injuries among US High School Athletes, 2005-2008. American journal of 

Sports Medicine 37(8);1586-1593 (2009). 

55. Yard EE and Comstock RD. Effects of Field Location, Time in Competition, and 

Phase of Play on Injury Severity in High School Football. Research in Sports 

Medicine: An lnternationaljournal17(1);35-49 (2009). 
117 


21158.088

56. Bonza ], Fields SK, Yard EE, and Comstock RD. Shoulder Injuries Among 

United States High School Athletes, 2005-2007. journal of Athletic Training 

44(1);76-83 (2009). 

57. Huffman EA. Yard EE, Fields SK, Collins CL, and Comstock RD. Epidemiology of 

Rare Injuries and Conditions among US High School Athletes during the 2005-

06 and 2006-07 School Years. journal of Athletic Training 43(6);624-630 

(2008). 

58. Borowski L, Yard EE, Fields SK, and Comstock RD. The Epidemiology of US 

High School Basketball injuries, 2005-2007. American journal of Sports 

Medicine 36(12);2328-2335 (2008). 

59. Yard EE, Schroeder M], Fields SK, Collins CL, and Comstock RD. The 

Epidemiology of US High School Soccer Injuries, 2005-2007. American journal 

of Sports Medicine 36(10);1930·1937 (2008). 

60. Collins CL and Comstock RD. Epidemiologic Features of High School Baseball 

Injuries in the United States, 2005-2007. Pediatrics 121(6);1181-1187 

(2008). 

61.lngram ]G, Yard EE, Fields SK, and Comstock RD. Epidemiology of Knee 

Injuries among Boys and Girls in US High School Athletics. American journal 

of Sports Medicine 36(6);1116-1122 (2008). 

62. Rechel ]A, Yard EE, and Comstock RD. An Epidemiologic Comparison of High 

School Sports Injuries Sustained in Practice and Competition. journal of 

Athletic Training 43(2);197-204 (2008). 

63. Collins CL, Fields SK, and Comstock RD. When the Rules of the Game are 

Broken: What Proportion of High School Sports-Related Injuries are Related 

to Illegal Activity? Injury Prevention 14(1);34-38 (2008). 

64. Yard EE, Collins CL, Dick RW, and Comstock RD. An Epidemiologic 

Comparison of High School and College Wrestling Injuries. American journal 

of Sports Medicine 36(1);57-64 (2008). 

65. Gessel LM, Fields SK, Collins CL, Dick RW, and Comstock RD. Concussions 

Among High School and College Athletes. journal of Athletic Training 

42( 4);495-503 (2007). 

66. Nelson A], Collins CL, Yard EE, Fields SK, and Comstock RD. The Epidemiology 

of Ankle Injuries Among US High School Athletes, 2005-06. journal of Athletic 

Training 42(3);381-387 (2007). 

67. Shankar PR, Fields SK, Collins CL, Dick RW, and Comstock RD. Epidemiology 

of High School and Collegiate Football injuries in the United States, 2005-

2006. American journal of Sports Medicine 35(8);1295-1303 (2007). 

68. Fernandez WG, Yard EE, and Comstock RD. Epidemiology of Lower Extremity 

Injuries Among US High School Athletes. Academic Emergency Medicine 

14(7);641-645 (2007). 
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21158.089

69. Comstock RD, Knox C, and Gilchrist J. Sports-Related Injuries Among High 

School Athletes United States, 2005-06 School Year. Connecticut Medicine 

71(1);19-21 (2007). 

70. Comstock RD, Knox C, YardE, and Gilchrist J. Sports-Related Injuries Among 

High School Athletes- United States, 2005-06 School Year. ]AMA 

296(22);2673-2674 (2006)- UAMA reprint of MMWR). 

71. Comstock RD, Knox C, YardE, and Gilchrist). Sports-Related Injuries Among 

High School Athletes- United States, 2005-06 School Year. Morbidity and 

Mortality Weekly Review (MMWR) 55(38);1037-1040 (2006). 
119 


21158.090

Appendix 2: Concussion Rates Over Time Among Athletes Participating in the 

Nine Popular U.S. High School Sports (Football, Boys' and Girls' Soccer, Girls' 

Volleyball, Wrestling, Boys' and Girls' Basketball, Baseball, and Softball) 

Which Have Been Under Continuous Surveillance Over the Past Decade, High 

School RIOTM Study, 2005/06 through 2014/15 

Concussion Rates per 1 0,000 AE 

~ 12 ~~~··~=C~nlR§lllliill~.~~:QJ~D~ll--=:EI~~k~.--··~~------~~---·-­

!3 $ 1Q 4~-·~-········-~~""""""""""""--""""""""""~C~-·~·-···~-···-~·~···-·-·-·--·---~~- <.) 

~ 

~ 0 

0 

0 

ci 

8 +~~--·~~-~~~~~---~~-·~·-···-----.. ---·--·--··~-·-·····---

6t-~~~---=~~-~---~=~~=~~=~·-

4 -~--~-·--··-·····---··--~"""""""-""""~:~~~~--""""""""-·--~·""·-······-~-----

2 1---~::::=~=::::::::::: 

0 +--~---~-"7""-·--r---~--~--~--""T·--~-~ 

Colorado School of 
120 


21158.091

Appendix 3: Concussion Rates Among U.S. High School Athletes Vary by Sport 

and Type of Athletic Activity, High School RIOTM Study, 2014/15 

Colorado School of *Competition includes competition and performance 

AE =Athletic Exposure with one athlete participating in one practice or competition 

representing one athletic exposure. 
121 


21158.092

Appendix 4: Improvement in U.S. High School Athletes' Compliance with 

Return to Play Guidelines Over Time, High School RIOTM Study, 2005/06 

through 2014/15 

% of HS Student Athletes in Each Category of RTP by Year 

Season DO 2.8 3.6 4.6 4.1 4.4 3.0 2.6 2.4 

Note: column o/o's do not sum to 100% because not all return to play categories 

captured by High School RIOTM are displayed in this table. Rather, only those 

categories indicating a failure to comply with return to play guidelines (i.e., <1 day, 

1-2 days, and 3-6 days} or indicating concussions of particular concern or interest 

(i.e., all others included in this table) are presented. 
122 

Mr. MURPHY. Thank you very much, Doctor. 

Now, Dr. Talavage, you’re recognized for 5 minutes. 

STATEMENT OF THOMAS M. TALAVAGE 

Dr. TALAVAGE. All right. Thank you very much, Chairman. 

So I’m Thomas Talavage. I’m a professor of electrical computer 

engineering and biomedical engineering at Purdue University, 

founding codirector of our MRI facility. I’ve been a member, in recent years, of the NCAA’s Task Force on Concussions and I’m a 

member of the Scientific Advisory Board for the NCAA–DOD CARE 

Consortium. And I’m also one of the founding members of the Concussion Neuroimaging Consortium, which is a multi-institutional 

effort to bring together the researchers who have a history of publishing and doing research in the area of concussion and traumatic 

brain injury together to solve many of these problems. I serve for 

the Purdue Neurotrauma Group as our specialist in neuroimaging, 

and I’m also the lead PI for the Purdue College of Engineering’s 

preeminent team on engineering healthier brains. 

As a rabid sports fan of the Pittsburgh Steelers and the Pittsburgh Pirates and the father of four very, very active young children, this is an issue that is very near and dear to my heart and 

has been for a long time. 

As a part of the Purdue Neurotrauma Group, I just wanted to 

summarize really quickly that our goals and our proposal into the 

future is to achieve safer participation in youth sports. Our goal 

here is to make sure that more children can participate in sports 

more frequently without really risk of injury, or at least a reduced 

risk of injury to something that is acceptable to us, such as riding 

a bicycle or playing baseball or playing basketball. 

Our goal is to achieve the same through the education of athletes, parents, coaches, and health care providers regarding the 

risks of not only concussive, but also subconcussive injuries 

through engineering-based improvements in protective equipment, 

through modeling and appropriate preventative methodologies that 

allow us to monitor exposure to head injuries and the risk of head 

injuries, and, finally, through techniques such as have already been 

described with improved training of athletes. 

Through the past 7 years, our pioneering study has been engineering based as following the model illustrated on the slide, where 

we’re applying structural health monitoring, a technique developed 

from basic materials and basic structures in our everyday world, 

whether they be planes, bridges, automobiles, where you essentially do nondestructive evaluation, you document that a material 

is in good health before you continue forward with its use, and as 

that material starts to exhibit some sort of change, you effect either 

repair, or in the case of some materials, you allow them to rest, allowing them to recover. 

This methodology has been applied now, as I said, for 7 years in 

the study of high school girls playing soccer and boys playing football. And our study, though, applying this methodology began like 

most of the other studies in this domain, where our real initial effort was to understand why some kids got a concussion and some 

kids didn’t. But what we discovered very rapidly and has essentially driven our research since that time is that, in truth, many 

123 

of the children who we think are not injured are, in fact, showing 

changes in their physiology, changes in their brain that are strongly suggestive of underlying brain injury. 

And what’s really critical is that not only are athletes who are 

supposedly healthy, who do not have signs of a concussion, who are 

not diagnosed or even examined by their team’s athletic trainer or 

their team’s physician as having a concussion, will look abnormal 

in this manner for up to 5 months after the season, which means 

that they may be spending 8 to 9 to 10 months of the year in an 

abnormal state. 

So while we already know ahead of time that it’s never a good 

idea to hit your head, the question now becomes how long is it that 

these athletes are injured and what can we do to prevent that injury in the first place? So our study has, as I’ve already mentioned, 

been going for 7 years, and if we are able to find funding some time 

in the future, we will continue to study, ideally later this year. 

I only wish to be working from this methodology with the goal 

being that if we understand how inputs, in this case mechanical inputs of heads being hit, whiplash events from the body being hit 

and the head snapping to the side, snapping forward, or rotating 

abruptly, will allow us to understand how each of those events affects the brain. Then we can go back and now correctly develop 

protective technologies, helmets, that will in fact prevent concussion rather than merely skull fracture. We can develop appropriate 

methodologies for identifying when an athlete should skip a practice, because clearly we want the kids to miss practice, not the 

games, and that’s obviously what the kids want. And we will also 

then be able to evaluate whether or not recovery has been truly 

complete. Can we actually document that an athlete who has been 

pulled and is getting ready to return to play looks healthy enough 

that it makes sense for them to go back into play? 

So with that, we really feel, as the Purdue Neurotrauma Group 

and as myself as a researcher in engineering, that most of these 

changes can be made with no cost to the enjoyment of the game, 

but they are very likely to improve the freedom or the comfort to 

engage in these activities without any substantial consequences beyond those associated with other noncollision sports, such as baseball, bicycling, or whatever. And we really feel that the science is 

far enough along, that these changes should be made now rather 

than to wait any more time such that 30 million kids every year 

are exposed to potential injury. There is no reason not to act. 

[The prepared statement of Dr. Talavage follows:] 

124 


21158.093

Written Testimony 

Thomas M. Talavage, Ph.D. 

Professor of Electrical & Computer Engineering, Biomedical Engineering 

Purdue University, West Lafayette, IN 

12 May 2016 

Summary of Major Points from Written Testimony 

The Purdue Neurotrauma Group (PNG) proposes to achieve safer participation in youth sports by (i) 

education of athletes, parents, coaches, and health care providers, (ii) improved protective equipment, (iii) 

automated monitoring of exposure to head accelerations, and (iv) improved training of athletes. 

The PNG study, initiated in 2009, represents the largest and most comprehensive study of youth athletes 

exposed to repetitive head blows to-date in high school-aged girls and boys, playing soccer and football. 

A substantial number of statistically-significant short-term effects of repetitive head blows have been 

observed in the PNG study: 

o Decreases in functional MRI activation contrasts associated with working-memory task completion. 

o Decreases in MR spectroscopy-detected concentrations of neural metabolites. 

o Decreases in functional MRI measures of resting-state connectivity. 

o Decreases in functional MRI measures of regulation of neurovascular coupling. 

o Increases in white matter fractional anisotropy as assessed using diffusion-weighted MR imaging. 

Longer-term effects observed in the PNG study, by comparison of pre-participation assessments of soccer 

and football athletes with peers who do not participate in collision-based sports, provide evidence of 

neuroprotective/repair mechanisms that persist for at least several months after participation. 

These short- and long-term alterations, and their associations with exposure to head collision events, 

strongly suggest that limitation of exposure to head accelerations will reduce short-term consequences of 

participation and likely contribute to a reduction in the observation of concussion. 

Achievement of reduction in head acceleration event exposure is technically feasible, and should enable 

more youth to participate in more activities without increased risk of head injury. 
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Executive Summary 

The Purdue Neurotrauma Group (PNG) has studied head injuries and the related changes in neurophysiology for 

seven years and our data set represents the largest and most comprehensive study of young male and female 

athletes exposed to repetitive head impacts to date. Our results demonstrate that the number of head impacts 

per week and their magnitude must be limited and that this monitoring is technically feasible. To achieve the 

goal of wider and safer participation, the PNG proposes the following four steps be taken. These are (i) 

improved education of stakeholders regarding what may be regarded as "safer" levels of head acceleration 

events and how to avoid inducing such events during practices, (ii) improved protective equipment, with 

emphasis on preventing energy transmission to the skull and brain, (iii) automated monitoring of athletes for 

exposure to head accelerations that are likely to contribute to brain injury, and (iv) improved training of athletes 

to minimize head acceleration (i.e., collision and whiplash) events. 

The Study of Repetitive Subconcussive Injury In Youth Athletes 

Since 2009, the PNG has conducted a longitudinal (within-season) and cross-sectional (across-season) evaluation 

of the effects of repetitive subconcussive exposure to head acceleration events in high school-aged athletes 

participating in contact sports. This study, comprising over 420 athlete-seasons of cognitive and advanced 

neuroimaging assessment in high school-aged girls playing soccer and boys playing football, represents the 

largest study to-date of the effects repeated subconcussive exposure and the linkage to traumatic brain injury in 

youth athletes. 

Traumatic brain injury results from head accelerations that cause damage to the central nervous system. There 

are a variety of ways that this can happen and whiplash events may be just as dangerous as direct head impacts. 

Damage is ultimately caused by the dissipation of energy which, at the level of the brain, must occur through 

deformation of tissue (i.e., stretch and compression, typically quantified by strains), fluid movement, and 

mechanical disruption (e.g., cell rupture, myelin de-bonding, and synaptic derangement). While it is possible for 
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a single large blow to the head to cause any or all of these effects and result in symptoms, it is fortunate that 

these types of head impacts are relatively rare (Daniel et al. 2012). It should be noted, however, that even small 

head accelerations can produce these consequences within a localized region and, if the rate of healing does not 

keep up with the rate of damage accumulation, the athlete would be expected to eventually experience 

symptoms, even in the absence of any particularly large hits. In fact, every head impact or whiplash event would 

be expected to produce a unique spatial pattern of strains, and repeated exposure to such events increases the 

chance that the locations of maximum strains will overlap, resulting in these locations being progressively 

damaged over time. Eventually, the local tissue will have its resistance to injury reduced, or the small tears will 

preclude normal operation of the cells, much the same way in which overuse injuries (e.g., running or marching 

with heavy packs) may lead to stress fractures. 

Over the past seven years, PNG has been the first to document statistically significant changes in brain structure, 

function, and chemistry in living football and soccer players who were not diagnosed with a concussion (Poole et 

al. 2014; Talavage et al. 2014; Abbas et al. 2015b; Svaldi et al. 2016). Two important features of these observed 

changes should be noted. First, they have been observed to affect a large fraction (30-60%) of players on the 

teams studied to date (Breedlove et al. 2014; Nauman et al. 2015; Talavage et al. 2016). Second, they have 

repeatedly been observed to be best-correlated with the measures of cumulative acceleration exposure, be they 

the number of head collisions experienced or the aggregate energy incident on the head (Breedlove et al. 2012; 

Svaldi et al. 2016). Taken together, it is clear that head accelerations (a more general term to encompass both 

direct blows to the head or whiplash events associated with blows to other locations on the body) that do not 

result in a near-term diagnosis of concussion can still cause cellular-level injuries that accumulate over time. 

It is critical to note that the neuroimaging literature strongly suggests that some level of injury can be sustained 

without immediate presentation of symptoms. Damage or alterations in functional capacity at a single location 

in the brain need not produce corresponding changes in behavior (Viswanathan et al. 2015). Such injury could 
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range from ionic imbalance (Hovda 2014) to neuronal membrane damage (e.g., widening of the Nodes of 

Ranvier) that has not yet precluded delivery of information in the brain (Ouyang et al. 2010). 

The potential for hidden/covert damage is what makes repetitive brain injury so insidious, and is hypothesized 

to have confounded past investigations into the causes and consequences of concussion. A critical concept for 

understanding "concussion" and the difficulty in quantifying its causes, is that an individual should not be 

expected to exhibit symptoms until information flow is interrupted, or at least sufficiently disrupted so as to 

reduce the reliability of neuronal summation in place and/or time. Rather, provided that the flow of information 

through the brain is not wholly impeded, behavior should be expected to be within normal performance limits, 

albeit possibly being considered more strenuous. Even if a location within the brain has been impaired such that 

information cannot pass through it, the presence of multiple pathways by which information may reach the 

intended destination within a necessary time frame may preclude any symptoms being evidenced by the 

individual. Therefore, it is likely that the entire communication process must be interrupted or significantly 

delayed for a failure ofthe system (i.e., a concussion) to be observed. 

Overview of the Purdue Neurotroumo Group Study 

The PNG study uses structural health monitoring (Talavage et al. 2015) as a framework in which to detect 

disordered conditions in brain behavior before symptoms arise: while there is obvious value in improving 

treatment and return-to-learn/play protocols, the greatest benefit is to be gained from preventing the 

underlying injury. Once the biochemical cascades are initiated, it may be possible to intervene and mitigate 

subsequent damage (Shi 2015), but the most effective "treatment" is prevention of those cascades in the first 

place. 

Our study thus has initially been directed at characterization of brain changes associated with repeated 

exposure to subconcussive events (i.e., head accelerations that do not produce clinical observation of 
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symptoms) in youth athletes, particularly those exposed to repeated head acceleration collisions from sports 

such as football and soccer. 

Combining cognitive testing, advanced neuroimaging, and daily monitoring of head acceleration events, the PNG 

study (Figure 1) tracks athletes before, during, and after exposure to events that are likely to contribute to brain 

injury. We now have data from football and women's soccer teams at three high schools and one college, 

comprising 420 athlete-seasons, more than 1,300 MRisessions, and roughly 1,400 cognitive assessments. 

Partnering with multiple institutions (Bailes et al. 2015) conducting similar research via the Concussion 

Neuroimaging Consortium (http://www.concussionimaging.orgL our goal is to evaluate biomarkers derived from 

these varied assessments to better characterize the risk that an individual who has been exposed to 

subconcussive events will exhibit abnormal brain behavior, and how elevated their risk might be for subsequent 

diagnosis of concussion. 

Before discussing key findings of this study, it is critical to observe that a key component of the PNG study has 

not been widely replicated in any of the large, multi-institutional efforts currently being funded by federal 

sources. Specifically, the PNG study derives much of its benefit from the within-season longitudinal nature of its 

cognitive and neuroimaging assessments-the acquisition of a within-subject baseline, before 

participation/exposure, has proven to be critical to our understanding of both short- and long-term alterations 

in brain behavior and health. The value of a pre-participation assessment comes from the fact that most 

measures of brain function/physiology and cognitive performance used to study concussion exhibit appreciable 

population variance, complicating interpretation of differences between subjects. Within-subject changes in 

measurements, as a function of exposure, have frequently proven to exhibit greater variance than are exhibited 

across the source population priorto exposure. The ability, therefore, to recognize that a late-in-the-season 

individual no longer resembles the pre-participation population makes it straightforward to interpret changes in 

cognitive or neuroimaging biomarkers as meaningfully-related to the independent variable of exposure. Given 
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work by our group and others (McAllister et al. 2014; Johnson et al. 2014), the comparisons made in the large 

multi-institutional studies are at risk of revealing few differences between concussed and asymptomatic 

athletes. Lack of biomarker alteration due to concussion must not be misinterpreted to downplay the serious 

potential for long-term damage associated with this clinically recognized injury. 

Findings of the Purdue IVeurotrauma Group Study 

Several key short-term findings in high school-aged athletes have been obtained from the PNG study as a 

consequence of the longitudinal nature of the study within each of the seven seasons of study to-date. 

a) The initial finding of the PNG study-in boys playing football-was the presence of statisticallysignificant decreases in functional MRI activation contrasts associated with completion of a rather 

simple working-memory task. While such a finding might not be remarkable on its own, these decreases 

were observed when the subjects (a) did not exhibit alterations in task success, and (b) did not exhibit 

outward symptoms associated with a diagnosis of concussion-i.e. 1 were asymptomatic. Critically, these 

findings (Figure 2) proved to be best-correlated with recent exposure to head acceleration events 

(Breedlove et al. 2012; Talavage et al. 2014; Robinson et al. 2015), and the persistence of these 

decreases (Figure 3) appears to be related to average weekly exposure to head acceleration events 

experienced by the athletes (Breedlove et al. 2014; Nauman et al. 2015). 

b} A second finding in male football players was the presence of statistically-significant alterations in MR 

spectroscopic assessments of metabolite concentrations-in dorsolateral prefrontal cortex (DLPFC; a 

region associated with planning and executive function) and primary motor cortex (M1)-arising at the 

beginning of the period of exposure to collisions, and persisting throughout the competition season and 

beyond (Poole et al. 2014; Poole et al. 2015). 

c) An additional observation from male athletes participating in football (Abbas et al. 2015b; Abbas et al. 

2015c) was that measures ofthe network connectivity, as assessed using functional MRI, exhibited 

statistically significant drops in the periods following increases in the average weekly exposure to head 
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acceleration events-e.g., at the commencement of practices (typically associated with two contact 

activities per day), and late in the season (when activities intensify due to post-season tournaments). 

d) These findings were extended beyond male athletes to female athletes, with observation in functional 

MRI of decreased regulation of cerebrovascular reactivity (a measure of the coupling between brain 

activity and the vascular delivery of metabolites) in both male football and female soccer athletes 

(Figure 4) at the high school level, with the degree of this decrease in regulation linked to the number 

and aggregate energy associated with the history of head acceleration events as of the time of the 

assessment (Svaldi et al. 2015; Svaldi eta!. 2016). 

e) Finally, recent preliminary analyses further suggest that male athletes who are exposed to the highest 

levels of head acceleration events also exhibit the greatest increases in the directionality of the diffusion 

of water molecules in axonal tracts (i.e., increases in fractional anisotropy) as measured by diffusionweighted MR imaging (Chun et al. 2015; Jang et al. 2016). This increase in the directionality of the 

diffusion of water (Figure 5) suggests that extracellular spaces-which normally do not restrict the 

diffusion of water-have been decreased, potentially through chronic inflammation of the brain. 

In addition to these short-term observations, the cross-sectional nature of the study across seasons and 

associated comparison to peer controls (of like gender, and from the same high schools) who have not 

previously participated in contact sports, has highlighted population-level differences at the pre-participation 

assessment that suggest the presence of longer-term-possibly even persistent-alterations in brain behavior 

and health, that are likely to be undesirable for periods exceeding a few months (or even weeks) out of the year: 

a) Statistically-significant decreases in MR spectroscopy-assessed neural metabolites during the season, 

were found to represent drops from elevated concentrations priorto the season (Poole et al. 2014). 

b) Resting-state measures of brain connectivity, as obtained using functional MRI, were found to be 

elevated (relative to noncollision-sport peers) prior to the season, and to recover to these high levels 

once head acceleration levels stabilized during the season (Abbas et al. 2015b; Abbas et al. 2015c). 
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c) Further analyses of brain networking using graph theoretic approaches (Bullmore and Sporns 2009) has 

revealed a meaningful dependence of pre-participation connectivity on both the (self-reported) history 

of concussion and the history of participation in sports involving repetitive exposure to head 

acceleration events, with a continuum appearing to exist from healthy noncollision-sport athletes 

without a history of concussion to collision-sport athletes having a history of concussion, with collisionsport athletes without a history of concussion lying at an intermediate location (Abbas et al. 2015a). 

The tendency for both short- and long-term alterations to be associated with higher levels of exposure to head 

acceleration events strongly suggests that a key aspect to the prevention of subconcussive, and likely also 

concussive, injury is the limitation of exposure to such events. Approaches such as hit counts will not represent 

an ideal solution, when applied in a one-size-fits-all manner, but do represent an excellent first step in reducing 

the risks to youth athletes in regard to short- and long-term alterations in brain health. Enhanced modeling of 

individual athletes and continued exploration ofthe features of head accelerations that most contribute to 

subsequent alterations in cognitive and neuroimaging biomarkers can provide greater refinement in the future 

with regard to which events "matter" and are, therefore, appropriate to be "counted". More critically, the 

potential that there does exist some axis (dimension) along which there is a minimum threshold above which 

head acceleration events are increasingly likely to contribute to short- and/or long-term alterations in brain 

health would argue that enhancements in protective measures and training could both contribute to an ultimate 

solution that reduces the risk of brain injury in youth athletes. 

The Path ta Prevent/an 

Based on the findings above we propose the keys to safer participation include (I} improved education of 

coaches, officials, and parents regarding what may be regarded as "safer" levels of head acceleration events and 

how to control the incidence rate of these events during practices, (II} improved protective equipment, 

increasing the efficacy in preventing energy transmission to the skull and brain, (iii} automated monitoring of 
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athletes for exposure to those head acceleration events that are most likely to contribute to brain injury, and 

(iv) improved training of athletes to minimize head accelerations associated with collision and whiplash events. 

As detailed in Talavage et al. (2015), the PNG study provides not only a means to detect and characterize 

changes as a function of acceleration event exposure, but also provides a framework in which prevention and 

intervention may be evaluated. 

(i) Educating athletes, coaches, athletic directors, officials, parents, and even healthcare providers so that 

they understand the mechanisms by which athletes expose themselves to large head accelerations, is an 

important step forward. Eliminating tackling from practice (as per the recent Ivy League mandate) was 

found in our study (Talavage et al. 2015) to appreciably decrease the average number of head impacts 

and concomitant alterations in observed biomarkers. Even if contact activities are not eliminated, 

altering participation schedules to provide more days off between such activities is likely to be beneficial 

due to the potential for natural repair processes to mitigate the cumulative damage. 

(ii) Beyond using some form of hit count to reduce the total number of head impacts, it is practical to 

improve safety equipment, including designing padding and helmets that absorb more energy and 

reduce the total energy delivered to the brain. While this is, in fact, not a difficult problem to solve, 

efforts have been slowed by the fact that equipment certification has focused on mitigating skull 

fractures and other major trauma, as opposed to concussion. Current helmet designs therefore prevent 

massive trauma (largely by spreading the force out over a larger area), but do little to reduce the energy 

transferred to the brain. Once the limits of energy transfer beyond which brain injury occurs are 

identified, it will be readily feasible to develop new design criteria for helmets and standards that, when 

combined with current testing protocols, will both eliminate massive trauma and dramatically decrease 

the energy transferred through the helmet to the brain. 

(iii) The PNG study has demonstrated that substantial changes in brain behavior can arise in the absence of 

(obvious) symptoms, and that these changes may accumulate over time. Consequently, improvement of 

diagnostic protocols-including both (a) telemetry-based monitoring of the number and magnitude of 
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head accelerations, and (b) clinical follow-up evaluations possibly including an array (e.g., blood and 

neuroimaging) of biomarkers and cognitive testing-should be expected, in the near future, to 

dramatically increase sensitivity and specificity of clinical assessments. 

{iv) Continued educational protocols (akin to "Heads Up") in conjunction with the telemetry argued for in 

{iii), have significant potential for rapidly enhancing player skill level, leading to improved techniques 

that decrease player risk of head injury. For example, low-cost sensors that monitor the number, 

magnitude, and location of head impacts can provide feedback to athletes and coaches, allowing them 

to encourage less-risky play and game techniques in real-time, Rapid and appropriate correction of poor 

tackling, heading, etc. will permit athletes to participate more frequently and more safely. 

Concluding Thoughts 

The search for neuroimaging biomarkers has yielded potentially powerful insights into the mechanisms of brain 

injury while also redefining what we should consider "injury" to be. Based on the PNG study findings that 

decreased exposure corresponds to fewer and smaller changes in brain function, it is critical that research 

efforts be put in place to enhance preventative approaches to brain injury, rather than solely focusing on postinjury recovery. Effecting these preventative approaches will require participation from multiple stakeholders, 

including parents, coaches, officials, and healthcare providers. All must advocate for measures that will further 

the prevention of brain injury, including reduction of exposure to head impacts, introduction of adequate rest 

periods between contact activities, and appropriate education of all participants in the sporting enterprise. In 

conjunction with the further advancement of the science, this joint effort has the greatest potential for 

improving the overall safety of youth, with long-term positive consequences for this vulnerable population. 
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References 

Abbas, K., J. Go iii, et al. (2015a). History of Concussion Reduces Brain Resting State Network Efficiency. 

Biomedical Engineering Society 2015 Annual Meeting. Tampa, FL. 

Abbas, K., T. E. Shenk, et al. (2015b). "Alteration of default mode network in high school football athletes due to 

repetitive subconcussive mild traumatic brain injury: a resting-state functional magnetic resonance 

imaging study." Brain Connect 5(2): 91-101. 

Abbas, K., T. E. Shenk, et al. (2015c). "Effects of repetitive sub-concussive brain injury on the functional 

connectivity of Default Mode Network in high school football athletes." Dev Neuroosychol40(1): 51-56. 

Bailes, J., S. Bravo, eta!. (2015). "A call to arms: the need to create an inter-institutional concussion 

neuroimaging consortium to discover clinically relevant diagnostic biomarkers and develop evidencebased interventions to facilitate recovery." Dev Neuropsychol40(2): 59-62. 

Breedlove, E. L., M. Robinson, eta!. (2012). "Biomechanical correlates of symptomatic and asymptomatic 

neurophysiological impairment in high school football." J Biomech 45(7): 1265-1272. 

Breedlove, K. M., E. L. Breedlove, et al. (2014). "Detecting Neurocognitive & Neurophysiological Changes as a 

Result of Subconcussive Blows in High School Football Athletes." Athletic Training and Sports Healthcare 

6(3): 119-127. 

Bullmore, E. and 0. Sporns (2009). "Complex brain networks: graph theoretical analysis of structural and 

functional systems." Nat Rev Neurosci 10(3): 186-198. 

Chun, I. Y., X. Mao, et al. (2015). "DTI Detection of Longitudinal WM Abnormalities Due to Accumulated Head 

Impacts." Dev Neuropsychol40(2): 92-97. 

Daniel, R. W., S. Rowson, et al. (2012). "Head impact exposure in youth football." Ann Biomed Eng 40(4): 976-

981. 

Jang, 1., T. Talavage, et al. (2016). Collision-Sports and Axonal Impairment: DWI Assessment in High School 

Football Athletes. 22nd Annual Meeting of the Organization for Human Brain Mapping. Geneva, 

Switzerland. 
135 


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McCuen, E., D. Svaldi, et al. (2015). "Collegiate women's soccer players suffer greater cumulative head impacts 

than their high school counterparts." J Biomech 48(13): 3729-3732. 

Nauman, E. A., K. M. Breedlove, et al. (2015). "Post-Season Neurophysiological Deficits Assessed by ImPACT and 

fMRI in Athletes Competing in American Football." Dev Neuropsychol40(2): 85-91. 

Ouyang, H., W. Sun, et al. (2010). "Compression induces acute demyelination and potassium channel exposure 

in spinal cord." J Neurotrauma 27(6): 1109-1120. 

Poole, V. N., K. Abbas, et al. (2014). "MR spectroscopic evidence of brain injury in the non-diagnosed collision 

sport athlete." Dev Neuropsychol39(6): 459-473. 

Poole, V. N., E. L. Breedlove, et al. (2015). "Sub-concussive hit characteristics predict deviant brain metabolism in 

football athletes." Dev Neuropsychol40(1): 12-17. 

Povlishock, J. T. and D. I. Katz (2005). "Update of neuropathology and neurological recovery after traumatic 

brain injury." J Head Trauma Rehabil20(1): 76-94. 

Robinson, M. E., T. E. Shenk, et al. (2015). "The role of location of subconcussive head impacts in FMRI brain 

activation change." Dev Neuropsychol40(2): 74-79. 

Shi, R. (2015). Compounds and methods for treating multiple sclerosis. USPTO. USA, Purdue Research 

Foundation. 9,056,109. 

Svaldi, D. 0., C. Joshi, et al. (2015). "Cerebrovascular reactivity alterations in asymptomatic high school football 

players." Dev Neuropsychol40(2): 80-84. 

Svaldi, D. 0., E. C. McCuen, et al. (2016). "Cerebrovascular reactivity changes in asymptomatic female athletes 

attributable to high school soccer participation." Brain Imaging Behav. 

Talavage, T. M., E. A. Nauman, et al. (2014). "Functionally-detected cognitive impairment in high school football 

players without clinically-diagnosed concussion." J Neurotrauma 31(4): 327-338. 

Talavage, T. M., E. A. Nauman, et al. (2015). "The Role of Medical Imaging in the Recharacterization of Mild 

Traumatic Brain Injury Using Youth Sports as a Laboratory." Front Neurol6: 273. 
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Talavage, T. M., E. A. Nauman, et al. (2016). "The Role of Medical Imaging in theRe-Characterization of Mild 

Traumatic Brain Injury Using Youth Sports as a Laboratory." Front Neurol6. 

Viswanathan, V., S. Lee, et al. (2015). "Age-related striatal BOLD changes without changes in behavioral loss 

aversion." Front Hum Neurosci 9: 176. 
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Structural Health Monitoring 

Figure 1: Block diagram illustrating the concept of Structural Health Monitoring (SHM). The structure of interest 

is monitored for usage over time, and periodically assessed using non-destructive evaluation methodologies. 

Each such assessment permits categorization of the structure as being healthy ("O.K."), altered ("Weak") or 

severely damaged ("Failure"). Note that depicted images are intended only as schematic representations of 

data and/or associated analyses. From Talavage et al. {2016}. 
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Telemetry Outcomes 

(HITS"") 

Neuroimaging Outcomes 

(fMRI) 

Figure 2: Comparison of (left column) head impact maps and (right column) fMRI measurements of "verbal" 

(letter-based) N-back working memory task for three high school athletes in the pre-season and subsequent to 

exposure to repeated head acceleration events. One athlete (top row) experienced a relatively low number of 

small magnitude hits and did not exhibit significant changes between pre-season and in-season scans. A second 
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athlete (middle row) exhibited a large number of hits primarily to the top front of the helmet and, although not 

diagnosed with a concussion, exhibited statistically significant changes in neurophysiology. This athlete was 

representative of a new category of impairment observed in 30-60% of high school football players studied. A 

third athlete (bottom row) who was diagnosed with a concussion took a number of large hits (orange and red 

circles) and exhibited substantial changes in neurophysiology. Activation is depicted for a 2-back vs. 1-back 

working memory contrast, with preferential activation for the 2-back task indicated by orange-red coloration, 

and for the 1-back task by blue-cyan coloration. 
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30 30 

"' cS 28 c 

,.:: 

~ 26 

~ 24 ., "' 0 ., 0 

]22 

·~ • • • ~ ,.!). 

:t 20 

§ i 18 

::;; 

16 16 0 2000 1\ :Wil 

(a) (b) 

Figure 3: Relation of flagging category (lmPACTTM or fMRI or none) of players during post-season 

assessments, as related to the median magnitude of the blows taken over the course of the season and (a) 

the number of cumulative hits, or (b) average hits per week over the entire season. Open circles indicate 

that the subject's lmPACTTM and fMRI measures were within the normal range. Open triangles indicate 

that the subject's lmPACTTM test was flagged. Gray squares were used to denote those instances when at 

least 11 ROis of a subject's fMRI scan exceeded the 95% confidence interval. Finally, black diamonds 

indicated those sessions where the subject's lmPACTTM and fMRI were flagged. A gap in our data occurred 

between 600 and 900 cumulative hits. Players who sustained more than 900 cumulative hits had a 75% 

chance of being flagged, whereas players who sustained fewer than 600 cumulative hits had only a 36% 

chance of being flagged. Similarly, a gap occurred in our data between 60 and 80 average hits per week. 

Adapted from Nauman eta/. (2015). 
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~ 

.,. 

, 

l'l 

y 

T 

ll 

I I , I ~--~ 

u 

Season 

Figure 4: Box and whisker plots of cumulative peak translational acceleration (cPTA) and cumulative peak 

angular acceleration (cPAA) distributions for soccer athletes at each assessment session. Boundaries of boxes 

represent the 25th and 75th percentiles (1st and 3rd quartiles) and the line inside the boxes indicates the 

median (50th percentile) of the distribution. Assessment sessions /nl and ln2 comprise intermediate 

measurements during first and second half of the competition season; and Post represents groupings based on 

end of season cumulative totals. Athletes are grouped by individual rank above (HighLoad; n = 7) or below 

(LowLoad; n 7) the median Relative Cumulative Exposure (RCE; see text). Athletes in the Top group were 

observed to have experienced significantly greater cPTA and cPAA than athletes in the Bottom group at each 

session (PmR < 0.05, unpaired t-test). Note that the High Load and LowLoad groups are session specific-i.e., an 

athlete need not remain in the HighLood or LowLood group for all three assessment periods. Adopted from 

Svoldi et of. (2016}. 
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FA Change In Altered Region 

·0.02 

Control Mid Top 

Figure 5: Distribution of fractional anisotropy (FA) changes in white matter regions of interest indicate that high 

school-aged male athletes participating in football who experience the highest levels of repeat exposure to head 

acceleration events (Top) exhibit statistically significant increases in FA relative to their pre-participation 

assessment. This elevation of FA suggests that these athletes are experiencing inflammation of the brain 

(Povlishock and Katz 2005). Test-retest contrasts are indicated for high school-aged male athletes participating 

in non-contact sports (Control; N=15) in addition to three groups of football players, divided into thirds (upper= 

Top, middle= Mid, lower; Bot; N;15 in each) based on accumulated counts of head acceleration events 

reported by the xPatch (X2 Biosystems, Inc.) to exceed 20 g (McCuen et al. 2015). From lang eta/. (2016}. 
143 

Mr. MURPHY. Thank you, Doctor. 

I do want to recognize—I’m going to start off with some questions here and let the members know that we’re going to try and 

continue this. There will be one vote at some point. We’re going to 

try and continue on and roll through that vote. So we’ll just start. 

I do want to recognize in the audience, we have Nick Lowery, 

Nick the Kick, right, played for the New England Patriots, the 

Jets, and the Chiefs. Good to have you here today. Thank you for 

your interest in concussions. 

Also, Shawn Springs from the Ohio State, also the Redskins, Patriots, and Seahawks. I think you were the number one pick for the 

Seahawks, Pro Bowl. Both of you played Pro Bowl. Thank you for 

your interest also in concussions. 

And a former colleague, Phil ‘‘the Doc’’ Gingrey, is here as well. 

We appreciate you coming back. I do want to say he didn’t make 

the Georgia Tech team, but I do understand you drove the mascot 

car, the Ramblin’ Wreck. So it’s nice to know your skill sets were 

seen where they were placed by Georgia Tech. It’s a good thing. 

All right. I now recognize myself for 5 minutes. 

This goes to Dr. Gregory, Mr. Margarucci, and Mr. Stenersen. 

From the perspective of a youth sport organization, what are the 

greatest needs in terms of research related to concussions and player safety? Can you comment on those? 

Dr. GREGORY. Sir, for clarification, the greatest needs? 

Mr. MURPHY. Yes. 

Dr. GREGORY. So my first response would be to agree with Dawn 

Comstock that we have these databases in college and high school, 

and we don’t have them in youth sports. And so establishing a 

database for youth sports injury, I think, is imperative. 

Mr. MURPHY. Mr. Margarucci, do you have a comment on that? 

Mr. MARGARUCCI. Yes. I would echo Dr. Gregory’s statements, 

that we do need to have a database of injuries that are occurring 

in our youth sports so we can make these decisions. And it’s hard— 

we don’t want to wait for the future, but we need to start, I think, 

gathering some of this information right now. 

Mr. MURPHY. Mr. Stenersen? 

Mr. STENERSEN. I would agree. I mean, each of us as sports is 

trying to do our best to fund research to our nonprofitabilities, but 

we need greater resources here to be able to drive that research 

into the youths’ play area. 

Mr. MURPHY. So along those lines with research, do you encourage coaches? Is there a way to help coaches and teams also keep 

track of their own database? This also, I assume, Coach Teevens 

too, that coaches keep track of their own data to see what happens 

at their own coaching style as a comparison. Would any of you like 

to comment on that? 

Mr. STENERSEN. Well, I would say, and Dr. Comstock probably 

has a word here, but the challenge with that is the quality of the 

data that’s collected. And unless it’s collected well and consistently, 

which coaches, generally speaking, are not want to do, then we’re 

concerned about having flawed data. 

Mr. MURPHY. Dr. Comstock, do you have a comment on that? 

Dr. COMSTOCK. Yes, I agree. We are concerned about the quality 

of the data, and that is directly correlated to who’s reporting the 

144 

data. At the high school and the collegiate level, we rely upon certified athletic trainers, certified athletic trainers, to report this 

data to us. However, I and others have been investigating ways 

that we could modify our surveillance systems to enable either a 

parent or a coach who is trained appropriately and appropriately 

motivated to be able to report, perhaps not 300 variables per injury, but at least enough variables that we could drive forward a 

lot of these discussions. 

Mr. MURPHY. And, Coach Teevens, you did record, you did look 

for specific data. 

Mr. TEEVENS. Through the conference in general overseas and 

each medical team within the institutions report back. So it’s—— 

Mr. MURPHY. And that’s helpful to give the feedback, then, along 

those lines? 

Mr. TEEVENS. It is. You see where you stack up to some other 

teams in your league. 

Mr. MURPHY. OK. So let me ask the panel too. How significant 

is the issue of athletes not reporting concussions? So if they themselves have symptoms, but they’re not giving that information on. 

Can you comment on that? Who would like to comment? 

Dr. Gregory? 

Dr. GREGORY. Yes. So I can tell you at all levels that is an issue, 

that the problem’s being knowing what the symptoms of concussion 

are, and then if you report it to somebody, that person knowing 

what the symptoms of concussion are. So I do think that what 

Dawn showed with that data, that concussion rates are actually 

coming back down, I think is a result of education of coaches, athletes, players on what the signs and symptoms of concussion are. 

Having said that, I don’t think we can stop there. We have to 

continue those efforts so that everybody is aware of that. 

Mr. MURPHY. Anybody else want to comment on the player? 

Yes, Dr. Comstock. 

Dr. COMSTOCK. Yes, sir. Actually, that same graph that showed 

the doubling of concussion rates between 2008 and 2012, our high 

school athletes didn’t suddenly become twice as fast, strong, and vicious. The years preceding that, there were concussions occurring 

that just went undiagnosed, unrecognized. So the increase in the 

concussion rates, I think, truly reflect the great deal of education 

that’s been done by individuals on this panel as well as groups like 

CDC and CIPC, the National Federation of State High School Associations, to make sure that when a concussion occurs, it is recognized—— 

Mr. MURPHY. So it may not have been that prior to that increase 

that concussions weren’t occurring, it’s just they were just getting 

reported? 

Dr. COMSTOCK. Exactly. 

Mr. MURPHY. And that means educating the players as well as 

the importance of doing this. 

Dr. COMSTOCK. Yes, sir. And the parents and families and—you 

know, the parents of these young athletes. It’s important to educate 

them as well. 

Mr. MURPHY. Do you see this as an ongoing problem with regard 

to injuries that this is working or you still have a ways to go? 

145 

Dr. COMSTOCK. Well, I think the fact that that curve has seemed 

to have peaked and leveled off, I think it actually is an indication, 

coupled with the last slide that I showed that shows how much better we’re doing at managing concussions. I think both of those 

speak very highly to the success that we have had to date in educating parents, coaches, athletes, policymakers about concussion. 

We still have further to go, particularly in the younger groups. 

Mr. MURPHY. Thank you. 

I’ll yield now to Ms. DeGette for 5 minutes. 

Ms. DEGETTE. Thank you so much, Mr. Chairman. 

I want to take a look at some of the science that’s out there. And 

by the way, it was really an excellent panel with everybody giving 

a great perspective. 

Dr. Talavage, your work examines high school football players as 

well as high school soccer players. Can you tell us, from your research, about the head impacts from contact sports and how they 

impact head injuries? 

Dr. TALAVAGE. Yes. So what we’ve observed through our 7 years 

of study is that when the athletes take large amounts of blows per 

week, whether they be of a modest size, such as 10 G or above— 

10 G just as a reference, if you just stand up and drop down into 

your chair, you will generate roughly 10 times the force of gravity 

acceleration on your head. 

So when players are taking numbers of 60 to 70 blows per week 

in football, for example, then those male athletes tend to start 

showing alterations in their brain physiology that are suggestive of 

either damage to neurons or at least some sort of impairment in 

the way information passes around your brain, and ultimately results in you being able to respond to a question or to answer a task 

or to achieve a target on a game or particular activity. 

For our female soccer players that have been in our study, they 

do not take quite that number of blows, but one of the things we 

have observed is that they get hit pretty much every day. So in the 

State of Indiana, high school football is able to practice 2 days per 

week plus have a game. Soccer, there is no restriction. They tend 

to practice 5 to 6 days per week. 

So we do find that not only are there changes from the actual 

raw number of blows, how frequently they’re getting hit, but there 

strongly appears to be a consequence of how much time off are they 

given, which would suggest that there are natural repair mechanisms that we can exploit. And I believe that when we have these 

reduced contact cases, we are in fact benefiting our athletes. 

Ms. DEGETTE. Thank you. We had a forum in this committee in 

March, you heard us talking about it, and at that forum, there 

were some researchers who suggested that we don’t have enough 

science to act on this issue, and they said we should wait till 

there’s more research. What’s your response to this line of questioning? Very briefly. 

Dr. TALAVAGE. I don’t believe that. 

Ms. DEGETTE. And that’s because you actually have scientific research? 

Dr. TALAVAGE. We have now about 16 papers in publication and 

we are working now with several other institutions around the 

country, including Penn State University, Northwestern UniverVerDate Mar 15 2010 14:08 Apr 25, 2017 Jkt 037690 PO 00000 Frm 00149 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X145CONCUSSIONSPENDING WAYNE
146 

sity, Ohio State University, Michigan State University, and University of Nebraska to publish work that shows that there are, in fact, 

changes in the brain when you—— 

Ms. DEGETTE. If you wouldn’t mind getting that data to this 

committee, that would be very helpful for us in our investigation. 

Dr. TALAVAGE. Be very happy to. 

Ms. DEGETTE. Thank you. 

I just want to ask you a couple of questions, Dr. Comstock, about 

gender differences in concussions and head trauma. The surveillance data you collected shows that girls soccer has one of the highest rates of reported concussions among high school sports. What 

do we know about gender differences in concussion rates? Are girls 

more likely than boys to get concussions? 

Dr. COMSTOCK. Yes. That’s a million-dollar question, if you will. 

We first reported in 2007 that in gender-comparable sports, so 

sports that both boys and girls play by the same rules, using the 

same equipment on the same fields, sports like soccer and basketball, girls have higher concussion rates than boys. That’s now been 

replicated by other researchers in other populations. 

What we don’t know at this point, people are working on the 

question, is, is it a biophysiological problem, are girls somehow—— 

Ms. DEGETTE. Right. 

Dr. COMSTOCK [continuing]. Different—— 

Ms. DEGETTE. Right. 

Dr. COMSTOCK [continuing]. And are they really sustaining more 

injuries, or is it a sociocultural issue? Because we don’t have a definitive, objective diagnostic test for concussions, we’re reliant on 

self-reports, and young female athletes may be more likely to report it when they’re experiencing signs and symptoms. 

Ms. DEGETTE. But do we need to get more data? 

Dr. COMSTOCK. Well, we already have the data that’s consistently 

shown this gender difference. We do—— 

Ms. DEGETTE. But what do we need to prove, then? 

Dr. COMSTOCK. So this is one case where surveillance data isn’t 

enough. We do need more detailed research to try to determine are 

there biophysiological differences or is it a sociocultural issue. 

Ms. DEGETTE. And, Dr. Talavage, you’re nodding your head yes, 

you agree. 

Dr. TALAVAGE. Yes. I mean, this is exactly what the intent of our 

type of study is. If we can understand how the brains are changing, 

we can determine whether or not it takes less to do it. 

Ms. DEGETTE. And you’ve got girls and boys? 

Dr. TALAVAGE. We have girls and boys, 5 years—— 

Ms. DEGETTE. Now, Dr. Comstock, I’m almost out of time. I just 

want to ask one more question. 

Dr. COMSTOCK. Yes, ma’am. 

Ms. DEGETTE. You say that there’s no data for—there’s no surveillance for under high school ages. Do you think this is something 

that should be instituted so that people like you can get that data 

to see exactly what’s going on? 

Dr. COMSTOCK. Yes. I would love to do it. I’ll give you the name 

of ten other researchers that can. This is imperative. 

Ms. DEGETTE. Who should set it up? 

147 

Dr. COMSTOCK. My work has not been federally funded. I’ve had 

nine different funding sources in 11 years of surveillance. The 

NCAA funds their own system. I think it should be a Federal effort, but I don’t care if it’s a joint effort of every one of these organizations of youth sports. Somehow we have to get it done. 

Ms. DEGETTE. One has to do it. 

Dr. COMSTOCK. We have to get it done. 

Ms. DEGETTE. Thank you very much. Thank you for coming. 

Mr. MURPHY. Thank you. 

Just to remind members that votes are called. We’re going to 

continue to roll through. 

Dr. Burgess, you’re recognized for 5 minutes. 

Mr. BURGESS. Thank you, Mr. Chairman. I thank the panel for 

being here this morning. 

Coach Teevens, can I just ask you, I mean, your testimony, when 

I read through it last night, it was like, wow, this is a revelation, 

and it seems so obvious. Once you understand that, oh, my gosh, 

this is a repetitive injury, so you’re not repeating the injury during 

practice, and so the only contact is on game day. But that must 

have been kind of a hard decision to make, because, I mean, when 

I was a kid growing up, it was always repetition, repetition, repetition, practice, practice, practice. Remember the old commercial? So 

what—— 

Mr. TEEVENS. When I announced it to my coaching staff, they 

were waiting for the punch line. They thought I was kidding. But 

I put enough time and effort into it. I thought it was the appropriate approach to reduce injury with my players. 

Mr. BURGESS. And you feel now—of course, you, what, 5 years 

into this, you feel you have—— 

Mr. TEEVENS. It’s made a decided difference in the way that we 

practice, the safety. Peripheral injuries have dropped as well, just 

the confidence. My frontline guys practice through the course of the 

season. Defensively I had two players miss games this year. One 

had a high ankle sprain, and at our discretion we kept him out. 

Another had a lacerated kidney, a leg whip, a freak incident, he 

missed five games. That was it. 

So the regularity and the players—and I tell them, the rules of 

the game are get the guy on the ground; not injured, get him out 

of the game, get him on the ground. And you can teach that skill 

set. And we just—we practice it extensively, and I think we do a 

very good job, understanding it’s an injurious—there’s a risk playing the game, and we can minimize the risk. 

Mr. BURGESS. Let me ask you this, and maybe you—and I’m 

sorry I wasn’t here for your testimony, but when you go back and 

look at your record prior to instituting this program and in the 

years since, is there a marked difference? 

Mr. TEEVENS. We were 0 and 10, 2 and 8, and we ended up the 

last two seasons 8 and 2, and this past year 9 and 1. 

Mr. BURGESS. So you’ve become remarkably better as a coach in 

that time? 

Mr. TEEVENS. Yes. Appreciably better, appreciably so. 

Mr. BURGESS. Well, that’s, again, fascinating story. It seems so 

obvious when you look at it. OK. Repetitive injury: We’re going to 

148 

reduce the risk by reducing the repetition, then—I, you know, certainly want to thank you for—— 

Mr. TEEVENS. Quite simply, the more you hit, the more you get 

hurt. 

Mr. BURGESS. I want to thank you for bringing that—— 

Mr. TEEVENS. Thank you, sir. 

Mr. BURGESS [continuing]. To the committee today. I don’t—I 

mean, again, I don’t know that I was aware of that. I don’t know 

how I would have been aware of it. 

Mr. O’Neil, I wanted to ask you, because, you know, when I first 

started reading your testimony and Practice Like the pros, and I 

thought, oh, my gosh, that would be dangerous, wouldn’t it? Because, I mean, those are the guys that really—dreadful stories you 

read about people who actually try to hurt each other in a game. 

But you had the observation with watching a practice that you said 

it was almost like a ballet. Is that—do I understand that correctly? 

Mr. O’NEIL. Yes, sir, it is, in that, as we pointed out with the 

video, the players execute every aspect of the play in rehearsal for 

Sunday until the moment of imminent contact, at which point they 

break away from each other and pat each other on the back. 

In the high school level, the proof of the efficacy of this is in the 

State of Wisconsin, the only State that is adhering to our standards 

at this point, put the standards in 2 years ago for the 2014 season. 

The University of Wisconsin Medical School did a study that year, 

the results published last October. Wisconsin high school football 

cut its concussions by more than half simply by adhering to our 

standards. That’s a—that is a breathtaking number in our business, to cut your concussions by more than half in 1 year. The quality of Wisconsin football has never been better, the players are 

fresh and ready to play. It is the high school model of what Mr. 

Teevens is describing at Dartmouth. 

Mr. BURGESS. And has there been sort of widespread acceptance 

of that in the high school level? 

Mr. O’NEIL. I’m glad you asked. Coach Teevens and I went to the 

Wisconsin high school clinic about 7 weeks ago in Madison. Because of these restrictions and because the coaches need to know 

how to practice with less contact, we had enormous attendance, 

more than 125 coaches. And the greatest followup that we’ve experienced in our 30 clinics around the country, more than half of 

those coaches asked for copies of our videos so that they could take 

them, show them to their staffs, show them to their players, and 

teach their players in the 30 minutes, just 30 minutes of contact 

per week in practice, how to practice like pros or like the Dartmouth Big Green. 

Mr. BURGESS. You know, I can’t help but observe that Emmitt 

Smith won ‘‘Dancing With the Stars’’ a few years ago, probably 

based on that same concept. Because weren’t some pro players 

using essentially dance moves and ballet moves to improve their 

performance? 

Mr. O’NEIL. They were. And, Congressman, this—this approach 

of less contact in the pros actually dates way back to Bill Walsh 

at the 49ers in the 1980s, and has been refined and developed by 

his disciples along the way to a point where so many college players look forward to entering the pros in order to avoid the carnage 

149 

of 90 minutes, twice a week, full contact in college practice, and instead practice the way the Dallas Cowboys have for many years. 

Mr. BURGESS. Thank you very much. 

Thank you, Mr. Chairman. I yield back. 

Mr. MURPHY. I thank you. 

I now recognize Ms. Schakowsky for 5 minutes. 

Ms. SCHAKOWSKY. First of all, I want to thank the moms that 

were here. I want to thank Kelli Jantz and Karen Kinzle Zegel. 

Mr. O’Neil, you showed that video of Dr. Ann McKee answering 

my question at that—— 

Mr. O’NEIL. Yes, ma’am. 

Ms. SCHAKOWSKY [continuing]. At that roundtable. And I wanted 

to focus on CTE, because I think very little focus has been on the 

subconcussive brain injuries. And as she said, it’s about limiting 

the head injury that occurs on every single play of the game at 

every single level of the game. And I followed up that question to 

Jeff Miller of the NFL, he’s the chief person for health and safety, 

and said, what do you think? Is it—is CTE linked to football? And 

he said, ‘‘Yes, certainly.’’ 

And little did I know that this was a kind of explosion that happened outside, outside that room, and even has started some conversation about what is the future of football? Is there a future for 

the kind of football that we play? 

So there’s been a lot of talk about concussion, but I wanted to 

ask now more about CTE. So, Dr. Talavage, what does your research indicate about the effect that routine hits sustained by high 

school football players and younger have on brain function, even 

though they don’t rise to the level of concussion? What about CTE? 

Dr. TALAVAGE. So at this point, the linkage to CTE is a little bit 

nebulous from our—coming from our end. Obviously, from Ann’s 

end, where you’re able to look and see that individuals who have 

experienced larger numbers of hits over their career and over their 

lifespan tend to have more deficits and tend to be more likely to 

evidence CTE, as per brain banks, I think there’s at least good circumstantial evidence for there to be a clear linkage between the 

total exposure and the total amount of brain stress that’s accumulated from getting hit repeatedly day after day after day, year after 

year. 

Within our own athletes, though, what we can at least identify 

is that our athletes spend probably 5 to 8 months of the year in 

what appears to be a state of almost chronic inflammation. And 

when you have chronic inflammation, we know in the rest of the 

body that’s a bad thing in the context that the cells are not able 

to eliminate waste, they’re not able to bring in nutrients to keep 

those cells healthy. 

And so if what we’re seeing is, in fact, proven to be true in our 

continued study, that we do have a level of chronic inflammation 

essentially for 5, 8 months of the year, then we are definitely putting our athletes at risk of precisely the types of biochemical processes that are going to lead to CTE. 

Mr. SCHAKOWSKY. Is there any test for CTE before an autopsy 

after death? 

150 

Dr. TALAVAGE. There are several imaging methodologies that 

propose to identify the presence of Tau biomarkers within the body, 

but there’s nothing that has yet been confirmed. 

Mr. SCHAKOWSKY. My understanding is the kind of subconcussive 

events have to do with the brain inside the skull, and has virtually 

nothing to do with helmets? 

Dr. TALAVAGE. So a helmet can, in fact, absorb energy, and it 

would be very easy, in fact, to improve helmet designs, but the 

companies aren’t terribly interested in it at this point. Their goal 

is to meet the standards. The standards that are set forth are to 

prevent skull fracture and death on the field, which is clearly a 

goal, which they are very effective, but they do nothing to prevent 

concussion at this point in a meaningful sense. Energy absorption 

would reduce the amount of energy that reaches the brain. If you 

reduce the amount of energy that reaches the brain, you are going 

to reduce the amount of torsion, pulls, stress, compression on the 

cellular tissue. And if you do that, you will, in fact, start to see a 

reduction in the consequence of subconcussive hits. You should see 

a reduction in the observation of concussion, and you should, in the 

long term, see the reduction in the situation such as CTE. 

Mr. SCHAKOWSKY. Dr. Comstock, you don’t think that kids under 

what age should be playing tackle football? 

Dr. COMSTOCK. That’s actually—I’ve never made any recommendation. 

Mr. SCHAKOWSKY. Oh, I thought you said something about it. 

Dr. COMSTOCK. Yes. I am aware of other researchers that have 

given exact cut points. 

Mr. SCHAKOWSKY. Did someone on the panel say that? 

Mr. O’NEIL. I did, Your Honor—Ms. Schakowsky. Our organization is the one in five national organizations operating in this space 

that believes strongly that grade school boys and girls should play 

flag football exclusively, and that contact football should start in 

ninth grade with a transitional phase in seventh and eighth grade 

where in shorts and T-shirts, boys who intend to play in ninth 

grade begin to learn how to tackle and how to block using the 

state-of-the-art in tackling technique called Sea Hawks tackling pioneered by the coaches, Pete Carroll and Rocky Seto of the Seattle 

Seahawks; Mr. Seto, being one of our leading supporters and a fellow who tours with us and had made a number of videos for us. 

Mr. SCHAKOWSKY. Now, there’s been a good deal of pushback 

after Jeff Miller made his—his comment, Jerry Jones, the owner of 

the Dallas Cowboys, you know, has absolutely disregarded that. 

There’s actually been some mocking of that, and this idea of the 

conduction between manliness and football, I think, is really concerning. And I wanted just to ask—let’s see. I had a couple of other 

questions. 

Dr. Gregory, I am particularly—you know, if once all the—well, 

let me ask you before my time runs out. That USA Football’s guidelines limit full contact practices to four times a week, but I note 

that this represents more contact practices than at current higher 

levels of football, such as the college level and even in the NFL. 

So, you know, given all this evidence about repeated hits to the 

head, why hasn’t USA Football taken steps to further limit full 

contact practice for young children? 

151 

Dr. GREGORY. So the question is a good one, in that we recognize 

that tackling causes injuries. If you look at data that we do have 

in youth football—— 

Mr. SCHAKOWSKY. My time is up. So why haven’t you? 

Dr. GREGORY. So what we have instituted is ways of trying to decrease the number of hits that there are. The concern is if you take 

it away completely—— 

Mr. SCHAKOWSKY. What about the four times a week? 

Dr. GREGORY [continuing]. If you take it away completely, you 

still have to learn the skill. At the youth level, we don’t have the 

resources that you have at the high school or college level to teach 

the skill. That’s what we’re trying to do is teach the skill to learn 

how to tackle appropriately gradually over time. That is the goal, 

to do it well, to protect your head. 

Mr. HUDSON [presiding]. Thank you. 

At this time, I’ll recognize myself for 5 minutes to ask questions. 

Mr. O’Neil, thank you for the work you do. I appreciate the information you gave us today. You advocate that children under 14 

should not be permitted to tackle, and should be limited to high 

school athletes. How do we assure that young athletes learn proper 

tackling techniques so when they do enter game situations, that 

they are not going to resort to distinct or more dangerous tackling, 

head down, whatever the case may be? If they don’t get that practice when there’s—contact is not as hard as it would be later, is 

there a concern of them internalizing those techniques? 

Mr. O’NEIL. If staff would, possibly, allow me to queue up a 17- 

second video clip—— 

Mr. HUDSON. Sure. 

Mr. O’NEIL [continuing]. Of Rocky Seto, which is number 24 on 

our agenda here. 

Coach Seto is the guru of tackling. He and Pete Carroll had devised this system in Seattle that has become the standard in just 

2 years, introduced 2 years ago in the spring. They put out three 

videos. And as I say, Coach Seto tours with us. 

No, it’s not that. It’s a—as I say, number 23, Rocky Seto tackling 

in shorts. Just to answer your question, Mr. Hudson, is what we 

recommend in seventh and eighth grade, is rather than hitting 

each other, these boys need to learn in shorts and T-shirts. They 

need an introduction to weight training. They need some strengthening of their necks, which I think all the scientists here would 

agree is important in preventing concussion. They need to learn 

how to wear the pads and be ready with this gradual run-up to 

ninth grade to be prepared without the many, many collisions involved in youth contact football. 

As we heard from Dr. Ann McKee so eloquently 2 months ago, 

it’s the cumulative head trauma that causes brain injury. And you 

don’t want to start that at age 5, which is permissible, according 

to some of the organizations represented here today, boys of 5 

years old playing contact football is, in our minds, quite surprising. 

Any luck, Jake? 

Mr. HUDSON. We’ll look at the video after. 

Mr. O’NEIL. I will be happy to show it to you, Mr. Hudson. 

Mr. HUDSON. Thank you. 

152 

So are there examples of cases where young kids have not had 

contact, have been until they reach high school age where they 

have been successful and—— 

Mr. O’NEIL. Thank you for asking. Tom Brady, Eli Manning, 

Peyton Manning. 

Mr. HUDSON. I’ve heard of those folks. 

Mr. O’NEIL. Archie Manning has waxed eloquently in The Washington Post here just a few years ago. I think his phrase was, God, 

what a great game flag football is. 

My son, a quarterback at Tufts University, would not be playing 

college football if he hadn’t played flag instead of contact. It taught 

him everything he needed about reading defenses, making decisions, making good throws, all the teamwork, all the character 

building. Believe me, those who suggest that those qualities can 

only be developed in contact football have not heard my younger 

son and his teammates in the back seat of the car, as I drive them 

around, recounting their victories in flag football 4 and 5 years ago. 

The highlight of their athletic careers, they were already made 

football fans for a lifetime. They wore the NFL Jersey in playing 

flag. They came out of it healthy with an experience that has—has 

made them the young men they are. 

Mr. HUDSON. Great. Thank you for that. 

Coach Teevens, do you have any thoughts on this, just in terms 

of if you wait until you are older to start learning tackle techniques, is that going to be a problem? 

Mr. TEEVENS. If it deprives people of an opportunity, they are 

still going to catch up real quickly. One of nine kids, six boys, we 

all played football in high school, and that was it, and all had fairly 

successful careers. There are a litany of people that have gone on. 

I don’t think it’s absolute. The big thing is it to educate. If they 

are going to play a young age, educate them properly, start slowly 

and make sure that you deprive them of as much contact as possible. 

Mr. HUDSON. Thank you for that. 

Dr. Gregory, you have anything you want to share on this? 

Dr. GREGORY. I’ll only add in that I think if you are going to take 

the contact away, that the education piece on how to tackle is imperative, and that is the challenge for us in youth sports without 

the resources. I will also add that USA Football administers the 

largest flag football league in the country, and so, we are proponents of flag football. It isn’t USA tackle football; it is USA Football, which is all inclusive. And so, I think it’s important that we 

promote flag football as well. 

Mr. HUDSON. Thank you. 

Let’s go back to Mr. O’Neil. You organization is trying to change 

the culture of high school football advocating this limited contact, 

more akin to what’s being used at the professional level. Is your 

testimony—or in your testimony, highlight the fact that only one 

State has adopted your standards so far? In light of the successful 

outcomes in that State, have others expressed interest? 

Mr. O’NEIL. It’s a good question, Mr. Hudson. What we need is 

more participation from the State governing bodies around the 

country. And the word is traveling. We find that when the State 

governing body gets behind it, as happened in California 2 years 

153 

ago, a piece of legislation passed there for the first time in any 

State limiting contact on the practice field. 

But they invited us out for a tour. Coach Seto of the Seahawks, 

Coach Teevens, Anthony Munoz, Warren Moon, we hit four cities 

in 2 days, and we had enormous participation because the CIF, 

which governs athletics in California, made it mandatory for every 

State—for every coach in the State. So we saw 1,200 coaches in 2 

days. We are going to Alabama in July, same thing occurred there. 

A very enlightened State, an executive director who understands, 

has made our clinic, after seeing us last year, mandatory for every 

coach in the State. So we will greet a ballroom full of more than 

1,000 coaches in Alabama on July the 20th. 

Mr. HUDSON. Great. I’ve got 15 seconds. Any opposition you’ve 

received? You want to briefly describe that? 

Mr. O’NEIL. Oh, absolutely. I’ve dragged Coach Teevens to places 

where there were 450 coaches at a convention, and at our session, 

20 showed up, and the other 430 were standing out in the hallway 

saying that they didn’t want to hear it right now. Absolutely. It’s 

not like we’re having raging success. It’s very mixed around the 

country, and will be until, as I say, until the State governing bodies 

at least give us a hearing and mandate that all the stakeholders, 

not just the coaches, come into the room and hear what we have 

to say and see it on video. When they do, we almost never fail to 

convert. 

Mr. HUDSON. Great. Thank you. 

At this time, I’ll recognize Mr. Pallone for 5 minutes for any 

questions he may have. 

Mr. PALLONE. Thank you. Earlier this year, the Ivy League received significant press attention for their move to eliminate tackling during regular season practices. And the league now has no 

contact practices during the regular season, as well as strict rules 

about the amount of contact and practice during the spring and 

preseason. So I wanted to ask Mr. Teevens—if I’m pronouncing it 

correctly—you implemented these changes at Dartmouth several 

years before they were adopted by the Ivy League. What motivate 

you to reduce the amount of contact in your practices, and what 

was the initial reaction when you proposed those changes? 

Mr. TEEVENS. Well, the injury rate was the stimulus, and we just 

had too many guys going down, like what’s the story, concussion, 

all that type of thing resurfacing, and it just struck me we can do 

this in a better way, watching what we did during research on 

tackling, and we started to do it. It was not well received. Still not 

well received by an awful lot of people. I did make a recommendation through Robin Harris at the Ivy level, and it was a 5-minute 

discussion. All of the coaches that played against Dartmouth, they 

know how we played, they know how effectively we tackle, and the 

vote was unanimous. It was progressive in mindset to say Hey, this 

is the direction we should travel. 

Mr. PALLONE. And how have the rates of head injuries changed 

since you implemented these no-contact policies? Have you seen 

any other benefits? 

Mr. TEEVENS. Five years ago, I was, like, most programs in the 

country, maybe 15 to 20 during the course of the year, and this 

past season we had two—two preexisting situations, both young 

154 

men that can no longer participate. Our defense, which was nationally ranked, had zero concussion this year. Spring practice last 2 

years, if my numbers are correct, we’ve had zero in spring practice, 

and that’s similar to concussion season in college football. 

Mr. PALLONE. Great. In your opinion, are full contact practices 

necessary to ensure success on game day and for athletes’ future 

careers? 

Mr. TEEVENS. No, I don’t believe so. To the point of imminent 

contact, you can do everything you need to; you can replicate tackling styles on bags and pads and with sleds, and I really believe 

and I tried to convince high school coaches of this as well. You can 

do it at any level. I’ve got a 3-year-old grandson. I have him tackle 

pads off the side of the couch, and see he gets it. And I think that, 

again, crawl, walk, run, mindset can introduce skill sets that would 

be helpful down the road, but don’t have to be practiced live that 

frequently. 

Mr. PALLONE. Now, given the research, do you think that engaging in full contact practices three, four, five times a week bear significant risk for young athletes? 

Mr. TEEVENS. Without question. The more you hit, the greater— 

the greater the risk of injury. And by just eliminating, we’ve seen 

that, quite frankly, in all aspects of our game; shoulders, necks, 

backs, arms have diminished appreciably, and it’s made up a better 

football program. 

Mr. PALLONE. Well, thank you. 

I wanted to ask Mr. O’Neil. We’ve seen many different rule 

changes being implemented across sports, across leagues, across 

States. There has been some criticism that these rule changes 

upset the integrity of the game. What do you think about the recent announcement that Pop Warner is eliminating kickoffs and 

kick returns? Will that prevent brain injuries, in your opinion? 

Mr. O’NEIL. Good question, Mr. Pallone. My reaction is this is 

Pop Warner’s way of saying that grade school boys are not capable, 

physically, of playing the game the way it’s designed. This is—they 

are making our argument. They are making the argument that 

these boys should be converted to flag football until they reach a 

physical maturity at 14 or 15 to play the game the way it’s structured. We advocate no basic changes in the game. We also say, 

there will not be any further rule changes that we don’t believe 

that will make the game noticeably less dangerous. The game is 

the game. We don’t advocate any major change to it, but we do say 

very strongly, boys in grade school are not nearly prepared to play 

it the way it’s designed, the way adults play it. And, therefore, both 

boys and girls ought to be playing flag football until boys make a 

transition, if they choose, to play contact in ninth grade. 

Mr. PALLONE. So just so I understand, you’re not recommending—you don’t think any other changes would better protect 

the kids other than if they continue with the present play? 

Mr. O’NEIL. Mr. Pallone, it won’t be football if we continue to 

strip away the kick return, the punt return, the three-point stance, 

there are any number of proposals out there. We are opposed to all 

of them. We think that those are ways—likewise, heads-up tackling, heads-up tackling is an attempt to somehow sanitize the very 

difficult, very physical act of tackling. It can’t be done. Tackling is 

155 

tackling. Rocky Seto’s Seahawks’ tackling defines it exactly as it’s 

done, and should be done, at the three levels of football where the 

game should be played. If boys can’t tackle the way the technique 

was designed, they shouldn’t be playing contact football; they 

should be playing flag until such point as they are ready physically 

to play. 

Mr. PALLONE. I thank you. 

Mr. HUDSON. I thank the gentleman. At this time, I’ll recognize 

my colleague from Virginia. 

Mr. GRIFFITH. Thank you. Thank you, Mr. Chairman. 

I do apologize. I took my jacket off and over ran to vote, ran back 

in the rain, and I got wet. So I took by jacket off. I do apologize 

for that. 

Mr. HUDSON. You’re forgiven. 

Mr. GRIFFITH. Mr. O’Neil, my boys are 8 and 10. My 10-year-old 

tried tackle football. When my 8-year-old was 7, he played flag. It’s 

not available for him now. Have you all done some studies here? 

In all your testimony, have you done some studies on how many 

kids, because they are not ready to do tackle, actually drop out of 

the sport? 

Mr. O’NEIL. It’s a very—we haven’t, sir, but it’s a very, very good 

point. Football loses any number of good candidates for the fact 

that we throw these boys in unprepared physically at a young age. 

There is a sound bite—I’m now adding sound bites that I would 

like to play for you when we finish. But I have 1 minute of John 

Madden, my former colleague at CBS, the coach and broadcaster. 

He tells a story wherein his son coached ninth grade football at a 

school in California for 15 years. And John said to him, if you take 

a boy who did not play contact youth football, and he’s a pretty 

good athlete, match him up against the boy who did play contact 

football through grade school, how long would it take the boy who 

did not play to catch up with the skills of the boy who did? Joe 

Madden, his son, said to him, One week. One week it would take 

him to catch up to what supposedly had been learned by a youth 

contact player those 8 years that he took all that head trauma from 

age 5 to 13. 

Mr. GRIFFITH. And I appreciate that. 

I am going to have to move on. 

Dr. Comstock, I was intrigued with your testimony about young 

women have more concussions than young men. Do you find that 

to be true? Do you have an—is that true through all age groups, 

middle school, high school, and college? 

Dr. COMSTOCK. So in the age groups that we have, good surveillance data, it has been consistent, both with my data and other 

good surveillance systems, so across slightly different populations 

and the high school and collegiate age group. We, in the middle 

school and younger age group, we only have very small studies of 

like one league or one school district. Based on those, it appears 

it’s also so on the underage groups, but we don’t have national data 

to answer that question. 

Mr. GRIFFITH. I appreciate it. I’m sorry we have some limited 

time here. 

Mr. Stenersen—I apologize for my pronunciation—U.S. Lacrosse 

has invested in the development and deployment of the sports first 

156 

standardized coaching and officiating education curricula. In your 

testimony, you observed that properly trained coaches and officials 

are the most effective interventions for players’ safety. Is that conclusion based, at least in part, on the changes you’ve seen in injury 

rates since deploying the curriculum? 

Mr. STENERSEN. In part, yes. But it’s—it’s more based on kind 

of our fundamental belief that if you can’t teach a sport correctly, 

and according to the rules, the outcomes are going to be not what 

you want. 

So—and I would add that part of the challenge we see that 

hasn’t been mentioned yet is in youth sports such as soccer and lacrosse and ice hockey, I think we are seeing a significant privatization of the sport, which means that kids are playing more frequently, more games, at younger age levels. And that privatization 

in sports specialization is compounding this concern in our sport. 

Mr. GRIFFITH. OK. I appreciate that. You also mention that one 

of the biggest challenges is getting youth leagues in State high 

school associations to buy in to your standards. Why do you think 

this is a challenge? If you can be quick, I would appreciate it. 

Mr. STENERSEN. Culture and tradition. 

Mr. GRIFFITH. OK. And I have to tell you, the good news is my 

16-year-old daughter had a concussion this year, and they pulled 

her out for about 2 weeks. And, you know, she got it playing lacrosse. 

Mr. Margarucci, I’ve only got a minute left. Is there something 

you haven’t had an opportunity to touch on that you’d like to? Because by the time I get a question out, the time would be up. 

Mr. MARGARUCCI. No. 

Mr. GRIFFITH. Would you agree with these folks that the more 

we can do to train folks on how to do it right and how to do the 

checks right or the hits right—— 

Mr. MARGARUCCI. Yes. We have a lot of that built into your 

coaching education, the checking progression and everything like 

that already, which we’ve had. 

Mr. GRIFFITH. And do you have the same buy-in difficulties that 

Mr. Stenersen indicated he was having? 

Mr. MARGARUCCI. Yes, to a degree. Not all high school associations, hockey leagues, are governed by USA Hockey, and so we 

don’t have any influence there. 

Mr. GRIFFITH. Right. 

Mr. MARGARUCCI. So, again, there’s no uniformity, sometimes, 

amongst those leagues. 

Mr. GRIFFITH. And there is a lot of privatization, not only do you 

all have that, but Mr. Stenersen mentioned that, and my 8-yearold is also playing youth lacrosse, and that’s completely outside the 

city rec league any of the high schools or any of the school systems. 

It’s a private institution. 

Listen, I came back because I thought this was an extremely important hearing. I appreciate all of your testimony, and we’ll continue to work on this. And I yield back, Mr. Chairman. 

Mr. HUDSON. I thank the gentleman. At this time, I’ll recognize 

Mr. Tonko for 5 minutes. 

Mr. TONKO. Thank you, Mr. Chair. And I appreciate all of our 

witnesses being here today and having this panel of expert witVerDate Mar 15 2010 14:08 Apr 25, 2017 Jkt 037690 PO 00000 Frm 00160 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X145CONCUSSIONSPENDING WAYNE
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nesses is a good opportunity to have dialogue on how we can further enhance the safety of youth sports. 

I would like to ask some questions about changes to rules governing contact, especially for kids. 

And, Dr. Gregory, you are here as a member of the USA Football’s medical advisory committee. What can you tell us about the 

guideline changes USA Football has made to make the sport safer 

for young athletes? 

Dr. GREGORY. Well, as you’re probably aware, there are practice 

guidelines now in place to limit contact, which has, as part of the 

heads-up program, shown good evidence of decreasing injury, and 

that is limiting contact to 30 minutes per practice, no more than 

four practices a week, and no more than 2 hours in total length of 

practice. 

So, decreasing the number of potential hits, which has been 

shown to occur by limiting the amount of time. 

Mr. TONKO. Thank you. And it’s my understanding that USA 

Football does not operate its own teams? 

Dr. GREGORY. That is correct. So we can only make suggestions 

to the leagues that are underneath us. The same problem that all 

youth sports have. We want these leagues to follow our recommendations, but we can’t enforce them. 

Mr. TONKO. So, in other words, there’s—it’s just a recommendation? There’s no way to implement those guidelines? 

Dr. GREGORY. There’s no way to enforce it. We’ve got to get buyin, just like what my other colleagues have talked about here. By 

showing them that it works, get buy-in from these youth coaches. 

Mr. TONKO. And, Dr. Gregory, have you been monitoring the rate 

of injuries, particularly head injuries since implementing these 

changes? 

Dr. GREGORY. So in the three areas that we showed with the 

dataless youth football study, the Fairfax County information here, 

and in South Bend, Indiana, the programs that implemented the 

heads-up football, which is the educational proponent and the practice limitations, all injuries, head injuries, all went down in both 

practice and games. 

Mr. TONKO. Do you have any—do you know anything more than 

that, other than dropping in—— 

Dr. GREGORY. Well, I gave the numbers already, but I can give 

them to you again. 

Mr. TONKO. OK. No, just as long as the committee has them—— 

Dr. GREGORY. Yes. 

Mr. TONKO [continuing]. That will be fine. 

And we have heard from Coach Teevens about his success at 

Dartmouth in eliminating contact practices and from Mr. O’Neil 

about practice like pros advocacy for additional rule changes to reduce contact, particularly for young players. The whole Ivy League 

has now eliminated contact practices, and the NFL allows only 14 

contact practices over the 18-week regular season. 

Dr. Talavage—did I say that correctly? 

Dr. TALAVAGE. Talavage. 

Mr. TONKO. Talavage, I’m sorry. What do these measures, like 

reducing the number of contact practices and giving players longer 

158 

rests between such practices do for players, in particular, what is 

the effect as it relates to the brain? 

Dr. TALAVAGE. The more time off they have, the more opportunity there is for the body’s restorative practices to repair any 

damage that’s occurred from being hit. So the more time you can 

give them off, the less likely they are to be impaired, the less likely 

they are to be injured in the future. 

Mr. TONKO. Thank you. 

And, Dr. Gregory, given what the science is telling us, why has 

USA Football not considered stricter rules or guidelines to reduce 

or eliminate contact for young players? 

Dr. GREGORY. So what I will tell you is that what has been demonstrated, both at Dartmouth and then high school level, is it’s 

fairly new, and I would say it’s very compelling, and the challenge 

is can we replicate this at the youth level without the resources 

that they have at the collegiate and high school level? And that’s 

the difficulty. And, again, we can make recommendations; we can’t 

enforce it. So for us, we have to make sure that if we make a recommendation like that, that we back that up by understanding 

that it can be implemented if we recommend it. And that’s—that’s 

what we need the resources to do. 

Mr. TONKO. And yesterday, Pop Warner announced that it would 

eliminate kickoffs and kick returns to reduce head injuries. It will 

also reduce contact practice time from 33 percent to 25 percent. 

Dr. Talavage, do you think these measures will be effective at reducing head injuries for kids? 

Dr. TALAVAGE. They are a good start. We’ll say that much. The 

main issue, I think, just to tie back to one quick comment from before, is that eliminating one or two or three or four big hits per 

game isn’t going to have a terribly substantial effect. I’d be more 

excited about the reduction in the contact practice time. 

Mr. TONKO. OK. So those are—those would be the first additional 

changes that you would encourage? 

Dr. TALAVAGE. Yes. 

Mr. TONKO. Dr. Gregory, is USA Football considering similar 

measures? 

Dr. GREGORY. Considering—say that again. 

Mr. TONKO. Is USA Football considering similar measures as 

those introduced by Pop Warner? 

Dr. GREGORY. Well, so one of the things that’s pretty clear is this 

is an evolving game, so this is definitely up for consideration. And 

rule implementations like this would be looked at and studied and 

see if—if it does, indeed, have the same effect to youth that it has 

at other levels. 

Mr. TONKO. Thank you. 

Finally, earlier this month, committee Democrats sent a letter to 

Scott Hallenbeck, executive director of USA Football, about how 

the organization is ensuring the safety of young football players in 

addressing the risk posed by both concussive and subconcussive 

hits. We have asked for a response by May 25th. 

Dr. Gregory, can you confirm that USA Football will provide the 

committee with a response by that date? 

Dr. GREGORY. I can confirm that. Thank you. 

Mr. HUDSON. Thank you. 

159 

Mr. TONKO. With that, I yield back. 

Mr. HUDSON. Thank you, sir. 

At this point, we’ll recognize Ms. Clarke for 5 minutes. 

Ms. CLARKE. Thank you, very much, Mr. Chairman. 

I thank our ranking member. I thank our witnesses for bringing 

your expertise before us today. 

I’d like to talk about the change in culture. As we approach the 

issue, we have to address sports culture and the attitude of toughness. For a long time, kids have watched their idols deliver the 

hardest hits on the field and get the most fights on the ice. As we 

make changes to play and practice, we also need to ensure that 

that permeates the culture of sports as well. 

Look, my first question, Mr. Teevens, is do you believe that players are convinced of the importance of reporting concussions? 

Mr. TEEVENS. I think they are getting there. I think it’s incumbent upon the coaching staff to make players aware that it’s oK for 

coaching staff members, says, Hey, you tough guy, the old school 

mind set, players may not respond if it’s opened and it’s oK, culture 

sports it, they will report. 

Ms. CLARKE. OK. And do you believe that the coaches and the 

medical staffs at the higher levels of play take concussions seriously? 

Mr. TEEVENS. I think they do. I think coaching profession is conservative, and a lot of guys that have played less than 5 years ago, 

or started coaching 5 years ago or greater, they grew up in a time 

when you didn’t self-report; you didn’t know about concussive head 

injury, and a lot of people teach what they were taught as players. 

That’s part of the culture that needs to change. It’s a different 

time. 

Ms. CLARKE. There needs to be a disruption. 

Do you think that we have been successful in spreading that 

message? 

Mr. TEEVENS. Not as successful as we need to be, and the broader the better. Again, limiting the injury is—it’s what we’re all 

about. 

Ms. CLARKE. Mr. O’Neil, the same questions. How can we convince players and coaches to report concussions and treat them seriously? 

Mr. O’NEIL. Ms. Clarke, it’s a great question. And I’d say this to 

you, when we do our clinics around the country, we have quantified 

the 19 cases of suspected second impact syndrome that you heard 

about earlier this morning. We tell those stories in detail with 

video of the players involved. We tell the stories of catastrophic injury in an effort to scare straight through the coaches these young 

boys who need this information. 

I show my son’s concussions as an example. I showed how he lied 

about his symptoms, did everything to stay on the field. Only when 

confronted with an impact test that showed he had failed the cognitive efficiency index test, only then did he admit that, yes, he was 

suffering a concussion and he was going to have to miss 3 or 4 

weeks of play. 

It is a huge problem still in high school football, and we think 

it’s a subject about which we need to be direct with players. We tell 

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courage the coaches to tell the players the story of what catastrophic injury can be in their lives if they don’t report, self-report, 

and self-diagnose. 

Ms. CLARKE. Many kids try to model their behavior after the athlete they revere. We need to ensure that the athletes at the highest 

level of play, college and pro, are sending the right messages about 

taking brain trauma seriously. 

So, Mr. Teevens and Mr. O’Neil, what can the college and professional athletes and leagues do in carrying that message forward? 

Mr. TEEVENS. I think the coaches would have to drive that message. I say frequently, unless we change the way we coach the 

game, we won’t have a game to coach. And putting into place—we 

have an MVP, a mobile virtual player tackling device, that has 

been tremendous, because we now replicate a moving target at no 

risk of injury to the player tackling it. Steps like that. 

The players will follow the direction of the coaching staffs, and 

I think coaching to coaches is absolutely critical to get our message 

across. 

Mr. O’NEIL. Ms. Clarke, what’s effective for us is when we take 

these Hall of Famers around the country, Warren Moon tells the 

audience, he suffered his first concussion at the age of 7 on a practice field in California, needlessly, not in a game, in a practice at 

the age of 7, and tells his personal story about hiding symptoms 

and then coming to a recognition later in his career how foolish 

that was. 

We take Anthony Munoz around, and he tells a story of playing 

for a coach in Cincinnati who wanted to hit and hit and hit every 

single day, even the day before games on a Saturday. They’re hitting each other in goal lines and short yardages drills before a Sunday game. Then he said we had a new coach, and that coach took 

our approach, which is virtually no contact during the week. And 

he said, we won both ways, but he said I sure felt a lot better and 

my teammates did, too, in that second approach, which is so much 

more effective. 

Ms. CLARKE. Any of you have any comments about what you 

think the fans should be requiring of this sport? 

Mr. TEEVENS. I think fans should be aware of it as well, and it’s 

not gladiatorial, it’s we have someone’s child who is playing the 

game, and understand some of those big hits. The rules of the 

game don’t dictate taking people out of play by force and injury. It’s 

just get them on the ground. And if there is understanding that 

long term, people can be in jeopardy if we don’t change the way we 

approach the game. 

Dr. GREGORY. The other thing I would add is that the media 

which is on ESPN, the Hits of the Week, are not good hits, if you 

ask us. Right? That’s what’s being shown as a highlight. That’s not 

the goal. We’ve got to change that. 

Ms. CLARKE. We have to change the culture, then, that requires 

that everyone that is participating and reveres this game. 

With that, I yield back. Thank you, Mr. Chairman. 

Mr. HUDSON. I thank the gentlelady. I ask unanimous consent 

that the Institute of Medicine, National Research Council report 

entitled ‘‘Sports-Related Concussions in Youth: Improving the 

Science, Changing the Culture’’ be introduced into the record. 

161 

1The information has been retained in committee files and also is available at http:// 

docs.house.gov/meetings/IF/IF02/20160513/104914/HHRG-114-IF02-20160513-SD099.pdf. 

Without objection, the document will be entered in the record.1

I also want to do another promotion of the briefing that Congressman Butterfield and I are hosting on pediatric trauma, May 

24th. Encourage all my colleagues and any interested parties to attend that briefing. 

And, in conclusion, I would like to thank all of you, witnesses 

and the Members who participated in today’s hearing. A very important issue. I think we’ve gained a lot of insight today. 

I remind Members they have 10 business days to submit questions for the record. I ask all witnesses to agree to respond promptly to those questions. 

With that, the subcommittee is adjourned. 

[Whereupon, at 12:19 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

PREPARED STATEMENT OF HON. FRED UPTON

This hearing marks the second event of the committee’s comprehensive review of 

concussions. We first had a roundtable discussion in March that highlighted not 

only the gaps in our scientific and medical understanding of these injuries but also 

the risks they pose to all members of society. These injuries occur not only on the 

field of play or in service to the Nation, but also in the school yard, in auto accidents, or even something as simple as slipping on a patch of ice. They do not discriminate. 

There are no easy answers when it comes to head trauma. It may take time for 

research to provide the concrete answers the public demands but that is not an excuse for inaction. There has been tremendous progress in the last decade but we 

can, and must, do more. And this must be a collective effort as no one individual, 

group, or organization can solve this public health challenge. 

We are here today to examine what is being done to protect one the largest atrisk populations for concussions, youth athletes. Every year, in Michigan and across 

the country, tens of millions of children compete in youth sports. From community 

recreational teams to elite travel clubs, children have countless opportunities to engage in athletic competition. These activities provide tremendous benefits to our 

children, influencing their physical and psychological health, academic performance, 

and social well-being—both now and in the future. 

Despite these benefits, with everything we see in the press about concussions and 

the long-term effects of head injuries, countless parents are asking themselves, is 

it safe for my child to play sports? 

This is a difficult question to answer. To start, we know relatively little about the 

prevalence, effects, and long-term outcomes of concussions or head injuries in pediatric populations, including youth sports. This group has been dramatically underrepresented in existing research. Do children respond differently than adults? How 

does the developing brain respond? Does it heal faster or does it create long-term 

effects? These are just a few of the many questions science simply cannot answer 

at this point. 

In the absence of scientific answers, we look for opportunities to limit exposure 

to head injuries. Due to the nature of concussions, management of these injuries is 

difficult even in controlled settings such as pro sports where you have individual 

leagues with a limited number of teams and athletes. At the youth level, there are 

thousands of leagues, organizations, and clubs—making the challenge exponentially 

more difficult and harder to control. The adoption and enforcement of rules, policies, 

or education programs often depends on the commitment of individual leagues, 

teams, coaches, parents, and athletes. 

Some progress has occurred in recent years as a number of leagues and organizations are taking steps to limit contact in practice and games. Others are conducting 

outreach and education to improve awareness and understanding for coaches, parents, and athletes. Whether these efforts are effective or go far enough remains a 

question and one that we should continue to evaluate. Collectively, however, these 

efforts reflect a growing shift in the culture of sports regarding concussions and 

head injuries. Today’s discussion is an important step in the right direction. 

162 


21158.112

TO: 

U.S. HOUSE OF REPRESENTATIVES 

COMMITTEE ON ENERGY AND COMMERCE 

Members, Subcommittee on Oversight and Investigations 

May 11,2016 

FROM: Committee Majority Staff 

RE: Hearing entitled "Concussions in Youth Sports: Evaluating Prevention and 

Research." 

I. PURPOSE 

On May 13, 2016, at 9:30a.m. in 2123 Rayburn House Office Building, the 

Subcommittee on Oversight and Investigations will hold a hearing entitled "Concussions in 

Youth Sports: Evaluating Prevention and Research.'' 

In December 2015, the Committee announced plans to begin a comprehensive review of 

the causes, effects and treatments of concussions. On March 14,2016, the Subcommittee held a 

roundtable as the first step in the Committee's effort to begin a constructive dialogue about the 

risks of concussions and how we can address this public health challenge- not only for athletes 

and service members, but society as a whole. At the roundtable, Members and participants 

discussed what is known about concussions, what gaps exist in the scientific and medical 

community, why these gaps exist, and what is being done to address those gaps. 

This hearing is the second public event in the Committee's ongoing review and will focus 

on concussions in youth sports, specifically issues related to prevention and research. Estimates 

suggest that more than 30 million children (ages 5-18) participate in organized sports each year. 

Given the number and complexity of youth sports organizations, multi-sport athletes, disparities 

in the quality of coaching, and social and cultural intlucnces, youth athletes face significant risk 

of being overlooked in the event of an injury. 

II. WITNESSES 

Panel One: 

• Kelli Jantz, R.N., the mother of Jake Snakenberg and Concussion Advocate ; and 

• Karen Zegel, the mother of Patrick Risha and Chronic Traumatic Encephalopathy 

(CTE) Advocate . 

Panel Two: 

Eugene F. (Buddy) Teevens III, Head Football Coach, Dartmouth; 
163 


21158.113

Majority Memorandum for May 13, 2016, Subcommittee on Oversight and Investigation Hearing 

Page 2 

• Andrew Gregory, MD, Member of Medical Advisory Committee, USA Football; 

Pediatric Sports Medicine, Vanderbilt University Medical Center; 

• Kevin Margarucci, Manager, Player Safety, USA Hockey; 

• Steve Stenersen, President and CEO, US Lacrosse; 

Terry O'Neil, Founder, Practice Like Pros; 

• Dawn Comstock, PhD, Associate Professor, Department of Epidemiology, Colorado 

School of Public Health; and 

• Thomas Talavagc, PhD, Professor, School of Electrical & Computer Engineering, 

Weldon School of Biomedical Engineering, Purdue University. 

III. BACKGROUND 

Concussions 

Concussions are a mild form of traumatic brain injury (TBI). TBI occurs when normal 

brain function is disrupted by "a bump, blow or jolt to the head or penetrating head injury." 1 

There are three general classifications ofTBI severity: mild, moderate, and severe. In 2010, the 

Centers for Disease Control and Prevention (CDC) estimated approximately 2.5 million 

emergency room visits, hospitalizations, and deaths due to or involving TB 1.2 This data, 

however, does not account for those who were not treated, individuals treated through outpatient 

or primary care office visits, or those treated at federal facilities, including current and former 

members of the military. 3 Most cases ofTBI are mild (mTB[), otherwise known as a 

concussion, and these are the most likely cases to be treated outside of emergency rooms or to go 

unreported. Thus, the actual number of concussions sustained annually in the United States 

remains unknown, but it is likely a substantially higher number than CDC's estimate. 

Until recently, public discourse and research related to TBI focused heavily on moderate 

and severe TBJ. In the past decade, however, high profile events have increased public 

awareness of the risks and dangers of concussions (mTBI). This has invigorated the research 

community and led to significant improvements in the management and care of these injuries. 

Understandably, athletes and service members have been the focal point of public interest on this 

issue, especially given their heightened risk of injury and the potential for repetitive trauma. 

However, concussions pose a significant health risk to all members of society, and additional 

work remains to be done to ensure everyone receives the education, attention and care necessary 

1 Report to Congress, Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services, 

Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation (2014). available at 

http://www. cdc. gov ltraumati cbrai n injury /pubs/ congress_ epi_rehab. html. 2 1d. at 19. 

3 !d. 
164 


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Majority Memorandum for May 13,2016, Subcommittee on Oversight and Investigation Hearing 

Page 3 

to manage these injuries. Chart I provides a simplified summary of the correlation between 

population size and awareness/standard of care. 

Population Size 

Despite recent progress, significant challenges remain due to deficiencies in our scientific 

and medical understanding of the effects of concussions, including the history, causes, and 

symptoms, the short and long term effects, the variations based on such factors as age and 

gender, and the appropriate length of recovery. These gaps in knowledge hinder the 

development of effective protections, programs, and treatments to limit and mitigate the 

detrimental effects of concussions. 

In recent years, the federal government, athletic institutions, and others have partnered 

with the scientific and medical community to launch critical research projects necessary to 

address these knowledge gaps, as well as identify technologies and innovative products that have 

the potential to protect against or minimize the risk of concussions. At the federal level, the 

Department of Defense (DOD) is a leading sponsor of research into concussions. TBI has 

always been a concern for DOD, but until recently, most of this work was focused on moderate 

to severe TBI. However, 93 percent ofTBI in the military are concussions and 85 percent of 

these concussions occur "in garrison" (non-combat settings), prompting new attention to these 

injuries. Another leader in the federal space is the National Institutes of Health (NIH), in 

particular the National Institute of Neurological Disorders and Stroke (NINDS). In addition, 

both DOD and NIH have partnered with external entities- including the NFL and NCAA--on 

concussion research, as well as other federal stakeholders (the Centers for Disease Control and 
165 


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Majority Memorandum for May 13,2016, Subcommittee on Oversight and Investigation Hearing 

Page 4 

Prevention, the Department of Veterans Affairs, etc.). As an example, the NCAA-DOD 

Concussion Assessment, Research, and Education (CARE) Consortium represents the largest and 

most comprehensive study of sport-related concussions to date. Further research is being 

conducted by academic and medical research institutions across the country. 

Moving forward, effective leadership and coordination will be necessary to ensure the 

research community is working efficiently and collaborative!y to address the numerous gaps in 

our scientific and medical understanding of concussions. 

Youth Sports 

Youth sports are not only the largest population group of athletes, they are also the most 

underscrved when it comes to awareness and care for head injuries. Estimates suggest that more 

than 30 million children (ages 5-18) participate in organized sports each year. Given the number 

and complexity of youth sports organizations, multi-sport athletes, disparities in the quality of 

coaching, and social and cultural influences, youth athletes face significant risk of being 

overlooked in the event of an injury. In addition, pediatric populations, including athletes, arc 

significantly undcrserved or represented in current research. Little is known about the short- and 

long-term effects of individual or repetitive head injuries in younger individuals. 

However, progress has been made in recent years, reflecting a positive shift in the attitude 

towards concussions and head injuries in youth sports. For example, all 50 states and the District 

of Columbia have concussion laws, and some leagues have implemented policies to reduce the 

prevalence of head injuries in youth sports. USA Hockey raised the age for legal body checking 

to the Bantam age group (13-14 years) and implemented rules to prohibit any check to head or 

neck rcgion. 4 In November 2015, U.S. Soccer announced new initiatives to reduce the 

prevalence of concussions in youth soccer, "including the limitation and/or outright banning of 

heading the ball for players under the age of 13."5 Under this new protocol, children ages 10 and 

under are barred from heading the ball during any official practice or game, while players ages 

11 to 13 are limited to heading during training sessions.6 In addition, Pop Warner Football was 

the first youth football organization to officially limit contact during practices in June 2012, 

adding two new rules and amending one oftheir existing rules. The first rule bans full speed 

head-on blocking or tackling drills in which players line up more than three yards apart. The 

second rule reduces the amount of contact at each practice to a maximum of one-third of practice 

time. In addition to the new rules, Rule 14, which has to do with blocking and tackling 

restrictions, was amended to emphasize technique when it comes to teaching safe blocking and 

tackling. 7 

4

USA Hockey, Body-Checking Rule, available at, http://'.Vww.usahockcy.com/page/show/908033-body-chcckingrule. 

5 NBC Sports, November 9, 2015, No More Heading: US Soccer Unveils New Concussion Protocol for Youth 

Soccer, Andy Edwards, Available at: http://soccer.nbcsports.com/20 15/ll/09/no-more-heading-us-soccer-unveilsnew-concussion-protocol-for-youth-soccer/. 

6 !d. 

7 Pop Warner, Rule Changes Regarding Practice & Concussion Prevention. June 13, 2012. Available at: 

http://www.popwarner.com/ A bout_ Us/Pop_ Warner_ News/Rule_ Changes_ Regarding_Practice _Concussion_ Prev 

ention _ s I _p3 977 .htm. 
166 


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Majority Memorandum for May 13, 2016, Subcommittee on Oversight and Investigation Hearing 

Page 5 

While recent policy changes reflect a positive shift in attitude, questions remain about 

whether they go far enough. For example, due to concerns about the long-term consequences of 

repetitive-or sub-concussive-head injuries, some groups advocate eliminating head contact 

from youth sports or establishing a "hit count," similar to a pitch count in baseball. While these 

concepts appear logical and may ultimately be proven by science, a 2014 report by the Institute 

of Medicine and National Research Council (hereinafter, "!OM Report") found that 

"implementing a specific threshold for the number of impacts or the magnitude of impacts per 

week or per season is without scientific basis.''8 This is not to suggest that proposals advocating 

less contact or a ''hit count," for youth athletes are not without merit. In fact, ongoing research 

continues to suggest the need for greater attention to this concern. This example, however, 

highlights the challenge of developing appropriate policies in the face of limited and evolving 

scientific research of head injuries in youth populations. 

This challenge is further illuminated by numerous gaps in our scientific and medical 

understanding of head injuries in youth athletes identified in the !OM Report. After reviewing a 

large quantity of existing research, the authors observed a number of weaknesses and challenges 

that effect prevention efforts, including, but not limited to, a lack of injury surveillance data for 

athletes younger than high school age or for athletes participating in club or recreational sports 

outside of an academic setting; inconsistency in how concussions are defined in research; 

minimal attention to factors such as race, ethnicity, or socioeconomic status; limited research 

focused on changes in the brain for youth athletes following concussions, including the 

predispositions for multiple concussions or negative outcomes; the need for more clarity on 

differences between male and female athletes; and inconclusive evidence regarding the longterm effects of repetitive-or sub-concussive-head injuries.9 

Improving the safety of youth sports is not just about science. Culture plays a critical 

role in improving awareness, attention, and care for youth athletes. Despite recent progress in 

improving attitudes and appreciation ofthe risks of head injuries, the !OM Report noted that 

"there is still a culture among athletes and military personnel that resists both the self-reporting 

of concussions and compliance with appropriate concussion management plans." 10 Educational 

and training programs, such as USA Football's Heads-Up initiative, seek to enhance the level of 

awareness and knowledge of coaches, players, and parents, at all levels. These programs, 

however, are not enforceable and depend on the sustained commitment of all involved, and 

research is currently ongoing to evaluate the success of these initiatives. 

One of the greatest challenges for addressing concussion risks in youth populations stems 

from the volume and relatively decentralized nature of disparate leagues, club teams, and other 

recreational opportunities available to young athletes. Professional sports leagues are relatively 

'Institute of Medicine (!OM) and National Research Council (NRC). 2014. Sports-related concussions in youth: 

Improving science. changing the culture. Washington, D.C.: The National Academies Press, at 11. 9 (The examples provided in this memo reflect weaknesses that effect areas such as research and prevention. The 

memo docs not include all findings of the !OM report, especially those addressing concussion management and 

treatment, equipment standards, etc.) Institute of Medicine (!OM) and National Research Council (NRC). 2014. 

Spans-related concussions in youth: Improving science. changing the culture. Washington, D.C.: The National 

Academies Press, at 7-11. 10 !d. at 7 
167 


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Majority Memorandum for May 13, 2016, Subcommittee on Oversight and Investigation Hearing 

Page 6 

small populations governed by a set of enforceable rules. For example, in the NFL, teams are 

limited to less than one contact practice per week during the regular season. Many colleges 

follow a similar model, regardless of specific conference or NCAA rules, and the Ivy League 

recently announced unanimous agreement to eliminate all full contact from practice during the 

regular season, on top of already stringent limits on contact during the preseason and spring 

practice. The situation at the high school and especially youth levels is far more complex due to 

the number of different governing bodies, leagues, and teams. As a result, the health and safety 

of the largest population of athletes-and those who have the least amount of experience--

depends on the level of awareness, education, and care provided by their respective leagues, 

teams, coaches-many of whom are volunteers with minimal expertise-and parents. 

Many youth athletes will never play in high school, let alone at the collegiate or 

professional level. Research by the NCAA found that the probability of high school athletes 

competing in college athletics, across most major sports, was less than I 0 percent. 11 Only a few 

sports-ice hockey and lacrosse for both men and women-yielded a greater than I 0 percent 

probability at competing at the collegiate level. 12 Only 6. 7 percent of high school football 

players will play in the NCAA, across all divisions, 13 and only 1.6 percent of those collegiate 

football players will play in the NFL. 14 These numbers are important in the context of youth 

sports because most young athletes are there to have fun and enjoy the benefits ofteam 

competition. These experiences provide numerous health and developmental benefits and 

encourage continued physical activity later in life, whether through team sports or other avenues. 

Developing an interest in physical activity at a young age has tremendous benefits throughout 

life, demonstrated in this chart developed by the Aspen Institute as part of their Project Play 

initiative. 15 

Unfortunately, research suggests that participation in youth sports is declining. 16 While there 

are a number of factors influencing this decline, a 2014 espn WI Aspen Institute survey found that 

11 NCAA Research, "Estimated probability of competing in college athletics" (Updated April 25, 20 16), available at 

http://www.ncaa.org/about/resources/research/estimated-probability-competing-college-athletics. 

12 !d. 

13 ld. 14 NCAA Research, "Estimated probability of competing in professional athletics" (Updated April 25, 2016) 

available at http://www.ncaa.org/about/resources/rescarch/estimated-probability-eompeting-professional-athletics. 15 The Aspen Institute, Project Play, "Sport for All, Play for Life: A playbook to get every kid in the game," 

Ami/able at http://youthreport.projectplay.us/the-solution. 16 !d. at, http://youthreport.projectplay.us/the-problem. 
168 


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Majority Memorandum for May 13, 2016, Subcommittee on Oversight and Investigation Hearing 

Page 7 

87 percent of parents are concerned about injuries in youth sports, especially concussions. 17 At 

the time, a quarter of parents had considered preventing their child from playing a sport due to 

concerns about head injuries. 18 It is important, therefore, to ensure that parents have the 

information necessary to weigh the risks of head injuries against the benefits of sports and 

athletic competition. 

IV. ISSUES 

This hearing is focused specifically on the areas of prevention and research, and the 

following issues are expected to be examined at the hearing: 

• Effects on children and the disproportionate lack of attention on this large population 

group; 

• Policies or guidelines for practice and game situations; 

• Educational and training policies for athletes, coaches, and parents; 

The current scientific and medical knowledge around concussions in youth athletes and 

its effect on policy or rules development; 

• The role of culture in youth sports; and 

• Research related to youth athletes. 

V. STAFF CONTACTS 

If you need any assistance or have any questions, please do not hesitate to contact John 

Ohly or Brittany Havens of the committee staff at (202) 225-2927. 

17 Tom Farrey, ESPNW, "ESPN Poll: Most Parents have Concerns About State of Youth Sports." (October 13, 

20 !4) available at http://espn.go.com/espnw/w-in-action!articlc/1!675649/parents-concern-grows-kidsparticipation-sports. 

18 !d. 
169 


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21158.120

RocKY MouNTAIN 

HOSPITAL for CHILDREN 

At f're>byteriJo/St.Luke'> 

perienLe as thry a.rrempt to wordinate aue 

REA? hasgrvwn asiJ rramir1g resmm:e over thepa;t jive 

Hetuming w L:-3ming Following J CunLu;,slon (l'ElJlATRlCS Volume 132, Number 5, November 2013) 

Report is UEAP! 

Reginald Wushmgton, MD FMP, FAAC, FAHA 

; which stands lOr Remove/Reduce 

• Educate · Adjust/ Accommodate Pace, 

is a communitv·-ba.scd rnodd 

sion that was developed in 

Colorado, The early origins of REAP stem from the 

dedication of one typical school and its surrounding wmmunity after devastating loss of a 

freshman 10olbaH player to "Second Syndrome" in 2004. The author of REAP, Dr. Karen 

gency department to school district to the office 

team members outside the sehoul (Students, Parents waiting roorrL 

and Hcalthcare Professionals) to create a safety net 

l()r all students with concussion, Under Dr. McAvoy's 

direction from 2004 to 2009, the multi--disciplinary 

team approach evolved from one school community to one entire school district Funded by an education 

grant from the Colorado Brain Injury Program in 

2009, Dr, McAvoy sat down and wrote up the essential elements of good multi-disciplinary team concussion management and named it REAP. 

With the opening of Rocky Mountain Hospital for 

Rocky Mountain Hospital for Children 

Center for Concussion 

CenteMI<Jl Medical Plaza 

14000 E, Arapilhoe Rd,, Suite #300 

Centennial, CO 80112 

Phone: 720.979.0840 Fa){; 303.690.5948 

Th' 

Brain Injury 

Alliance of 

Colorado 

21158.121

Because it is important for each member of the Concussion Management 1eam to 

know and understand their part and the part of other members, Lhis manual was wriUcn for all of the teams, M information is <:specially pertinent to a certain group, it is noted hy a color. 

Pay dose attention to the sections in 

Certified Athletic 

Trainers {ATC}, Physical Education Teachers, Playground 

Supervisors, Schoo! Nurses 

and others ... 

For more s.pecific informatiorr, download the "Head$ Up: 

Conc:U$Slort in Hlgh School Sport$ or ConcU$Sion in Youth 

Sports"" from the CDC website: 

qk goy/Concuss)oo/HeqdsUplh!gh ;u;hool html 

Pay dose attention to the sections in Dl0.1.RKER BLlJE 

Pay dose attention to the sections in 

fms.rgency Department, 

Primary Care Providers, 

Nurses, Conc:ussion Spaciali!rts, Naur-Oiogi5ts, Clinical 

Neutopsychologlst_s and 

others ... 

Fot more spe.;ific information, download the free 

''HeJKls Up: Brain lnjury ill your Prad:ice>l frpm the CDC 

website: 

tool ldt.html 

Table of Contents 

How to Use This Manual 

Adjust/Accomrnodate 

Special Considerations 

.. Child: en., 
172 


21158.122

21158.123

\ 

t'/t 

More than 80% of concussions resolve very successfuHy if 

managed well within the first three weeks post-injury. 2 REAP sees 

the first three weeks post- injury as a "window of opportunity:' 

Research shows that the average recovery time for a child/adolescent 

is about three weeks, slightly longer than the average recovery time 

for an adult.3 

REAP works on the premise that a concussion is best managed by a Multi-Disciplinary 

Team that includes: the Student/Athlete, the Family, various members of the School 

Team and the Medical Team. 'fhe unique perspective from each of these various teams 

essential! 

The first day of the concussion is considered Day L The first day of recovery also starts 

on Day I. REAP can help the Family, School and Medical Teams mobilize immediately to 

maximize recovery during the entire three week "window of opportunity." 

> 

> 

> 

> 

> 

> 

> > > > 

> 

> > 

When it comes to concussion, the newest 

mendations are that kids and teens should be 

treated much mom conservatively than adults. Little 

is known about the long risks of concussion that 

occur in childhood and but there is 

concern that concussions can add up over time and 

cause permanent problems. 

21158.124

EVERY Member of Every Team is Important! 

Every team nas an essential part to t:)lay at certain stages oftfie recovery 

RUI lNG-OUT a 

for the next 1 to 3 weeks the FOJmily Teom and 

the School AcademiC Teamw1ll provide the may;rity of 

MANAGEMENT by REDUCING soctal/home and 

schoo!sumulatlcn 

when ail FOUR teams deCide 

dent/athlete !S back to pre·concuss10n 

i:!g, the Medica! Team can the Giaduated 

Return to Play (RTP) steps, PACE pag(L 

E 

1 

0 

m 

Multi-Disdp!inary Teamwork "" the safest wa

munage a concussion! 

multipte perspectives / 

21158.125

"$wona.pos.!':ibie. 

team$. 

!ndudlng:eompre-

·h&ru;Jyehistory, JWurf.)logk 

'()f mental status, rogniti'tfe functjojl, gnit omd·balane<;l". 

teams. 

• 3-f'. con:Hder referral to a Spe

ConctJ$!ik>n dklie-if .nifi symptomrtic

It is best prl!di<» that a medf!::;;d pro-

.be involved In the mc:irt:aaeme

each and e"'ety notjuat 

cover4fd by 

improven;ent i

21158.126

April19, 1990 September 19, 2004 

Encourage REST. 

21158.127

recover, you will be able to du more each day with fewer symptoms, If trying to read an algebra book or going 

to the mall flares a symptom initially, the brain is simply telling you that you have pushed too hard today and 

the symptoms. They are .:ICtua!ly telling you the ralc of rewvery from Lhc concussion. 

NOTE: Home/social stimulation and school tasks can be added back in by the parent/tea<:her as tolerated, 

Physical activities, however, cannot be added back in without medical approvaj (see PACE), 
178 


21158.128

21158.129

STEP THREE· ADJUST/ 

A€!ZOMMODATE for EDU€A1f0RS:. 

And suggested adjustments/accommodations 

Difficulty concentrating 

Difficulty with 

working memory 

Reduce the \:ogn!tive load -it h. "fact that &maHer amounts of !earning wit! take 

during the re<ovlilry. 

Since learning during re<overy is the must dadde: 

the IT.OSt Important f-or the .rtudent to learn during this recovery? 

Be o.tl'eful not to tax the student <::CJgttltively by demandlrtg <11! !e<'!rning 

the rate prior to the con.cvsskm. 

!nftial!y exempt the from routine work/te£1$. 

Sioce memory dudng recovery is limited, the acildemk team must decide: What 1

most importal'lt mm:ept{s) for the student to know? 

Work toward compruhenskm of a !e/T\illtGr ilmount of matol'!rial ver:;us rote memoriz

21158.130

NEGOTIABLE 

Work REQUIRED 

from schooL If more 

call a meeting with parents and seek a medical explanation. 

l Work REMOVED Adapted from Wilham Heinz, MD. 

Ac..ademic adjustments fall within the pervue of the classroom/schooL They are NOT determined by a healthcare 

professionat The teacher has the right to adjust up or down academic supports as needed, depending upoh 

haw the student is doing daily. MedJcai "release" from academic: adjl,lstments is not 

Suggested Academic Adjustments 

Kl;!cp in mind, brain c.;:!ls will he-.1l them

tle bit ea(h day. Students should be ab

plis.h more ,md more at sdmo! <:dch Ja

anJ !'i.:wer :.ymptorns. Therefore, 

r..:wvery, hd1.hc should require 

from the .;tudcnt. Hr the token

an tX<Kt:rbation of :,ymptom::., hd

hack <hwn work for a :-.hort time ,md 

tolerated. 

IIow the performs in the .:las

sential d:.1tu necdt<d by the heahhl,lft: 

<lt the of dcarance. Schools :>h

proce<>S in place by whkh a G

servlttions, thought:., ..:ono:rns lMck to 

and heahhcarc professional 

cowry. Jle.Jlihc,tre :

QUIRE input from teadwrs on cognit

bd(lrc approving the GraduatcJ Ret

lS:cc Tt•,lt:hcr Form 

lJIX.; Parents should sign <i Rdease 

tion al the and/m .tl the 

tAYile Ji.)r .:om

lwtween i>dwol and meJi..:dl 

Supplemental materials and 

loadable forms for teachers may b

RockyMount.ainHospita1ForChi!dre

21158.131

AKAHowdoi "cleared" from this concussion 

While 80 to 90% of concussions will be resolved in 3 to 4 weeks, a hea!thcare professional, whether in the Emergency Department or in a dinic, cannot pred

length or the course of recovery from a concussion, In fact, a hea!thcare professional should never tell a family that a concussion wlli resolve in X number of da

cause every concussion is different and each recovery time penod ts unique,, The best way to assess when a stLldentfathlete is ready to the pof "Returning-to-Play" is to ask these questions: 

Use the Symptom Checklist every few days. AH symptoms should be at "0" on the check!is1 or 

at least back to the perteived "baseline" symptom leveL 

Look at what the student/athlete is doing. At home they should be acting the way they did 

before the concussion, doing chores, interacting normally with friends ar1d family. 

Symptoms should not return when they are exposed to the loud, busy environment of 

home/soda!, mall or restaurants, Your student/athlete should be handling school work to the level they did before the cont:ussion. 

Use the Teacher Feedback Form (APPENDlXl to see what teachers are noticing. 

Watch your child/Teen doing homework; they should be ab!e ro comp1ete homework as 

efficiently as before the concussion. 

r) ln-s(_hool test scores should be back to wtwre thBy were pre-concussion. 

School worklo<ild should be back to where it was pre-concussion. 

SyrnptOO!S should not return when they ilre exposed to the loud, busy environment of schooL 

) Ask ATC for feedback and/or serial administrations of the Symptom Checkli.<>t. 

) This. includes over the counter medicat1ons such as ibuprofen, naproxen and 

acetaminophen which may have been us.ed to treat headache or pain. 

REMOVE REDUCE ho

EDUCATE: Let the symptoms 

direct the interventions 

home/

school 

The true test of recovery is to notice a stead

crease in symptoms while noticing a steady in

fn the ability to handle more rigorous home/

and school demands. 

PARENTS and TEACHERS try to add in 

home/soda! and school activitit>s Uust NOT ph

activities) and test out those brain ce!!sl 

Once the answers to the questions above aall "YES," turn the page to the PACE page 

what to do 

21158.132

A Graduated Return-to-Play (RTP) Recommended by The 2012 Zudch Con'""'"' Statement on Concuosion in 

I AC'!'IVf;tY! FUNCTIONAL !icXERCISE AT EACH STAGE OF REfiA!liLITATl0!\1 oa.IE"CT!VE ()!;ST

No activity 

Light aerobic exercise 

exercise 

Non-contac.t training drills 

Fufkontact practice 

Return to play 

Sympto.m limited physkiai and cog11itiv.e re!it 

Wu!king, swimming or cyding keeping intemity <lfY'k m<Jximum pe-rmltutd 

Mart ra!'iL No resistanu: training. 

Skating drills in ics hockey, fi.Jllning clriHs iri socr;er_ No 

Progression to more complex training dnlt:S, e g., passing drfl!s in football and ice hodty 

May start progres-sive resistance training 

Fol!owing medical de01cance, in ltormat training .activities, 

Nurm11J game p!dy. 

Rox:overy 

!ncrea:J;e-hfJortr<.>te 

Add mo.,emem 

Exen:1$t', coordlnadon and cog

Restore confidence ,;_ncl 

ski!!;; by coaching staff 

No restrictions 

lh«: heaithc:are should gwe the ntt$ponsiblhty of the graduated RTP steps over only to a trmned profess,ona! such as an ATC, PT or should teach the parents. A coach, school nu

NOT rmBO to be responsible for taking concuss(!:d stw::lent/ilthletes thro.Jgh thes€ steps 

ReMN!lrdl Note: Earlier IntroductiOn ol phy::;ical ts being resa<lrched and mz.y become best pract•ce However, at thts time, <my e;,rly introductton of physH;:al exertion should only 

a supervts,;,d ilfl"d saf"" envtmnment by tramed pmfessJonab. 

21158.133

However, there rernaim theW to 2fJIVu of studentiat.hletes who have physical, cognitive, emotional or sleep/energy 

;,ymptomh wdl beyond the 3 to 4 week mark. In those wses, the !J<lXentand profe,sionalsare advised tn look to the 

,>ehool system for crhtingsuppmh. The oflDEA (Individuals with Disability Education Ad) introduced 

an educational initiative calh:d tu lli\Crvcmio:l {RTI)."RTI contend;-, thd! good teaching and reasonable 

"adjustments" in the general edw::ut1nn da:.stoom nm hdr to support 80 to 90tM, of ;,tudcnh with mild/temporary learning 

m bdwvioral issu6. The same concept holds trm: for ;;xmcus.siom. We have called to Management (RTM)." 

The 10 to 20% of who struggle beyond genera! education dassrnum may 

ne:c<l .J.:;m<llldmount of"targett:d inlcrveJttion" 

called ac.J.demic uaccornmndation," Academic 

"accommodati{)m" may be provided via a 

Health P!an,a Leam!ng Plan, a 504 P!ann or <1n 

RTl lt is stil! hoped that the accornmo· 

datiom im learning, behavior or concussion::. arc temporary and amenable to intervention 

but may take mnnths (imtead of weeks) for progress tu show. Lastly, with lUI and RTM, in 

the rare event that <1 permanent "di.-;abi1ity" is 

for lhe eUucllHllhd '-truggle, the: 

student may anJ StdffeJ into sp<Tidi 

education <>erviccs (IDEA) and provided an JEP (lndivid· 

ua!ized Education Plan). This would constitute dfl extremely small number of students with a mncus1>ion. 

The multi-disciplinary team!. need to continue \() 

work together with the student/athlete with protracted 

Concussion Management Guidelines 8 

recovery, Parents and professionals need to &eek 

medical explanation and treatment for :;!owed recovery; 

eduGJlors need to continue to pmvide the appropriat.e supand the school team needs: to continue to 

keep the out of physical play. 

21158.134

Colorado Brain Injury Program 

Brain Injury AIUance 

of COlorado (BIAQ 

Colorado High School Ac.tlvities 

Association {CHSAA) 

tbicolomdo.org 

biacolor<}do.org 

;;;hs=.org 

Coae.hes Training: National Federation of 

(free, online coat:h-training sessions} State H'1gh School Associations 

Th,spubiJ<:alii>n<snot;;sub5lltu::efOJs.oekrng 

mediu.!care. 

K""'"' McAvoy@llecr!rhONE,-<>H!S com 

REFERENCES 

303-866-4779 

303-355-9969 303-344-5050 

nf'hsleam.org 

Color.:.do Bra\"1 Injury Progr.<m far grant lundmg oC:era Lund and the Ltmd bmdy 

Th<> progom •s p<>rt of Rody H

21158.135

Name: ----------------------------------------- Assessment Date: ---------·------------------------

Date of Injury: Time of Injury 2·3 Hrs 24 Hrs 46 Hrs 72 Hrs Daily W

li:tili!iial•Jt'li: ::r"'ill'Ji\lalljrniiio'll•i!::J,:.oolfl!lJ~'!;tillllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

Pathwa'/5 Symptom,. 

A ! fee! fike I'm going to faint 

V I'm having trouble balancing 

0 Things look bhmy 

l see double 

N 

S/E 

I have headaches 

The light bothers my eyes 

! have pressure in my head 

I feel nJ.Jmbness and tingling 

I feel like I am not getting enough sleep 

I have !ow energy (fatigue} 

l feel tired a lot (drawsiness} 

Cog ! have trouble paying attention 

! am easily distracted 

! have trouble co.ncentrat!ng 

I have trouble remembering things 

i have trouble following directions 

I feel like my thinking is "foggy" 

! feel like I aro moving at a slower speed 

l don.'tfeel "dgkt" 

i feel confused 

! have trouble l.aarning new things 

j feel more emotional 

!feel sil.d 

l feel nervous 

J fee! irritable or grouchy 

0 

D 

0 

0 

0 

MHd Mild 

2 

2 

2 

Mode rata Moderate 

Patflwaysof ~or"oeem; A""Autonomk v .. vestibular O"'Oc\Jiomotor H"'Heeclache (Migraine &1\ion-Migr.,;n,.) C"'C<~~!Vi<.ogenic N"'Neck Strain SJE,.Sleep/En6rgy Cllg"'Cognith.re £.,Emr:>tfona! 

Severe S
186 


21158.136

0 0 0 0 z z z z 

' ' t -1 

t ' 5' I ~ c 5' " m ~ 0 ~ • " " • "' ' 0 Vi ""I 0 Vi 0 Vi ::J 0 Vi 
187 


21158.137

21158.138

Jake 

Snakenberg 

Fund 

Dedicated to the Memory 

of Jake Snakenberg 

Apnl19, 

September 19, 2004 

1s to enhance the quailty of life for pediatric panem:s m 

tile Jiucky Mountam regwn 

To ensure 1he ongowg efforts w educme CDBches 2nd 

Online: wW>N.rmchi!dren.org/donatioll 

Mail to: 

Contact: Luanne Williams, Executi..,e Director 

303.839.6873 

Visit us at: www.rmchildren.org 

Find us on facebook.com/rmc:ht 
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21158.139
190 

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21158.140