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94–524 PDF 2015

IMPROVING SPORTS SAFETY: A MULTIFACETED 

APPROACH 

HEARING 

BEFORE THE

SUBCOMMITTEE ON COMMERCE, MANUFACTURING, 

AND TRADE 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

MARCH 13, 2014 

Serial No. 113–128 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

RALPH M. HALL, Texas 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

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 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

FRANK PALLONE, JR., New Jersey 

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 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

BEN RAY LUJAN, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

SUBCOMMITTEE ON COMMERCE, MANUFACTURING, AND TRADE

LEE TERRY, Nebraska 

Chairman 

LEONARD LANCE, New Jersey 

Vice Chairman 

MARSHA BLACKBURN, Tennessee 

GREGG HARPER, Mississippi 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

JANICE D. SCHAKOWSKY, Illinois 

Ranking Member 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

JOHN A. YARMUTH, Kentucky 

JOHN D. DINGELL, Michigan 

BOBBY L. RUSH, Illinois 

JIM MATHESON, Utah 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

HENRY A. WAXMAN, California (ex officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Lee Terry, a Representative in Congress from the State of Nebraska, 

opening statement ................................................................................................ 1 

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

Hon. Janice D. Schakowsky, a Representative in Congress from the State 

of Illinois, opening statement .............................................................................. 4 

Hon. Leonard Lance, a Representative in Congress from the State of New 

Jersey, opening statement ................................................................................... 5 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 6 

WITNESSES

William L. Daly, Deputy Commissioner, National Hockey League ..................... 8 

Prepared statement .......................................................................................... 11 

Answers to submitted questions ...................................................................... 181 

Dave Ogrean, Executive Director, USA Hockey .................................................... 20 

Prepared statement .......................................................................................... 22 

Answers to submitted questions ...................................................................... 188 

Jeff Miller, Senior Vice President, Health and Safety Policy, National Football 

League ................................................................................................................... 27 

Prepared statement .......................................................................................... 30 

Answers to submitted questions ...................................................................... 196 

Scott Hallenbeck, Executive Director, USA Football ............................................ 42 

Prepared statement .......................................................................................... 43 

Answers to submitted questions ...................................................................... 203 

Briana Scurry, Former Professional Goalkeeper, U.S. Women’s National Soccer Team ............................................................................................................... 52 

Prepared statement .......................................................................................... 54 

Richard Cleland, Assistant Director, Division of Advertising Practices, Bureau 

of Consumer Protection, Federal Trade Commission ........................................ 73 

Prepared statement .......................................................................................... 76 

Answers to submitted questions ...................................................................... 209 

Ian Heaton, Student Ambassador, National Council on Youth Sports Safety ... 84 

Prepared statement .......................................................................................... 86 

Robert Graham, Director, Aligning Forces for Quality, National Program Office, George Washington University ................................................................... 89 

Additional material submitted for the record 1 .............................................. 90 

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

Answers to submitted questions ...................................................................... 214 

Dennis L. Molfese, Director, Big 10-CIC-Ivy League Traumatic Brain Injury 

Research Collaboration ........................................................................................ 102 

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

James Johnston, Assistant Professor, Department of Neurosurgery, University of Alabama-Birmingham .............................................................................. 109 

Prepared statement .......................................................................................... 112 

Answers to submitted questions ...................................................................... 218 

Timothy J. Gay, Professor, Department of Physics and Astronomy, University 

of Nebraska-Lincoln ............................................................................................. 129 

Prepared statement .......................................................................................... 131 

1The report ‘‘Sports-Related Concussions in Youth: Improving the Science, Changing the 

Culture’’ and the accompanying slide presentation have been retained in committee records 

and also are available at http://docs.house.gov/Committee/Calendar/ 

ByEvent.aspx?EventID=101897. 

Page

IV 

Gerard A. Gioia, Chief, Division of Pediatric Neuropsychology, Children’s 

National Health System ...................................................................................... 141 

Prepared statement .......................................................................................... 143 

Answers to submitted questions 2 222 

Martha E. Shenton, Professor of Psychiatry and Radiology, Brigham and 

Women’s Hospital, Harvard Medical School ...................................................... 153 

Additional material submitted for the record 3 .............................................. 154 

Prepared statement .......................................................................................... 155 

2Mr. Gioia did not answer submitted questions for the record by the time of printing. 

3 A supporting document has been retained in committee files and also is available at http:// 

docs.house.gov/meetings/IF/IF17/20140313/101897/HHRG-113-IF17-Wstate-ShentonM20140313-SD001.pdf. 

(1) 

IMPROVING SPORTS SAFETY: A 

MULTIFACETED APPROACH 

THURSDAY, MARCH 13, 2014 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON COMMERCE, MANUFACTURING, AND

TRADE, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:22 a.m., in room 

2322 of the Rayburn House Office Building, Hon. Lee Terry (chairman of the subcommittee) presiding. 

Members present: Representatives Terry, Lance, Harper, Guthrie, McKinley, Kinzinger, Bilirakis, Johnson, Long, Upton, 

Schakowsky, Sarbanes, Matheson, Barrow, Christensen, and Waxman (ex officio). 

Staff present: Charlotte Baker, Press Secretary; Kirby Howard, 

Legislative Clerk; Nick Magallanes, Policy Coordinator, Commerce, 

Manufacturing, and Trade; Brian McCullough, Senior Professional 

Staff Member; Shannon Taylor, Counsel, Commerce, Manufacturing, and Trade; Tom Wilbur, Digital Media Advisor; Michelle 

Ash, Democratic Chief Counsel, Commerce, Manufacturing, and 

Trade; and Will Wallace, Democratic Policy Analyst. 

Mr. TERRY. I want to thank everyone for being here, and we are 

now with the full committee ranking member, the gentleman from 

California joins us. We now have the ability to start our hearing. 

So I will introduce you after my statement and before you start 

your testimonies. So I will open with my opening statement. Morning, Jan. 

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

So good morning and welcome to this morning’s hearing. Today, 

it is my hope to learn what steps are being taken to make sports 

participation safer for all athletes. 

Every day, parents make choices about whether or not to let 

their son or let their daughter play soccer, or what kind of mouthpiece to buy their son for his first day of Pop Warner football. Unfortunately, it seems like every day we hear about how participation in certain sports can be dangerous. It is easy to understand 

how what parents see in the news inevitably affects youth participation in sports. 

Case in point: Earlier this year, President Obama said publicly 

that if he had a son, he wouldn’t let him play pro football. Then 

the First Lady wants us all to move. Seems to conflict. Messages. 

2 

So now, we want a better understanding of the innovations being 

made by sports leagues, equipment manufacturers, and the medical 

community to make all sports safer. One clear example is the NHL 

which has been working hand in hand with the NHLPA to make 

hockey safer. Dating back to 1997, the NHL recognized the dangers 

of head injuries and took the proactive step of forming a Joint Concussion Committee. Additionally, the NHL also established a Department of Player Safety at its headquarters, the first of its kind 

for any professional league. USA Hockey and USA Football, two organizations that help oversee youth sports in the United States, 

have followed the lead of their professional counterparts by employing a multipronged approach to making participation safer. USA 

Hockey now requires coaches to complete an Online education module specific to the age group they are coaching at, and that includes 

safety information, concussion education, and proper techniques. 

USA Football, which is endowed by the generosity of the NFL and 

the NFLPA, was the first national governing body for any sport to 

participate in the CDC’s heads-up concussions in youth sports. 

Initiatives and all engaged in providing youth with non-tackling 

alternatives to develop their skills. Additionally, USA Football’s 

Heads Up Football program encompasses 6 elements meant to 

make youth’s football safer, including coach education and concussion recognition. 

Proactive actions like the ones I just mentioned are exactly what 

parents need in order to be assured that everything possible is 

being done to keep their child as safe as possible while they are 

on the field or ice. 

Researchers have also been hard at work to improve the tools 

that coaches and doctors have at their disposal when treating an 

athlete. For example, Dr. Dennis Molfese, sorry, Doc, who runs the 

University of Nebraska’s Brain, Biology and Behavior Center located inside the Huskers Football Stadium, has been developing an 

MRI machine that can be used on game day to assess a head injury. This would allow medical staff to determine if a player has 

suffered a concussion, how severe the injury is, and if that player 

is able to return. 

Equipment manufacturers are also using technology to make innovation changes to helmets, mouth guards, footwear and other 

equipment, all in order to reduce injuries. I feel confident saying 

that given the recent rule changes and the rate which technology 

is advancing, playing a contact sport today is likely safer than it 

has been in the past, however, we must accept that there is no silver bullet, no helmet or pad is going to prevent 100 percent of the 

injuries 100 percent of the time. This is why we need to consider 

a multipronged approach aimed at keeping our kids safer, while 

still promotion youth participation in sports. This involves listening 

to how leaders like the NFL, NHL, youth leagues and top tier university researchers are partnering to make progress towards making sports safer. These are the types of innovations and paradigm 

shifts needed to give parents the assurance that all the possible 

steps are being taken to improve the safety of their child on the 

field. 

And I would like to thank our panelists for joining us here today, 

and willing to answer our questions. And I would especially like to 

3 

thank Dennis Molfese and Dr. Tim Gay for making the trips to 

Washington, DC, from Lincoln, Nebraska. 

[The prepared statement of Mr. Terry follows:] 

PREPARED STATEMENT OF HON. LEE TERRY

Good Morning-and welcome to this morning’s hearing.Today, it’s my hope to learn 

what steps are being taken to make sports participation safer for all athletes. 

Every day, parents make choices about whether or not to let their daughter play 

soccer or what kind of mouthpiece to buy their son for his first day of Pop Warner 

football. Unfortunately, it seems like every day, we hear about how participation in 

certain sports can be dangerous. It’s easy to understand how what parents see in 

the news inevitably affects youth participation in sports. Case in point: Earlier this 

year, President Obama said publicly that if he had a son, he wouldn’t let him play 

pro football. 

We want to better understand the innovations being made by sports leagues, 

equipment manufacturers, and the medical community to make all sports safer. 

One clear example is the NHL, which has been working hand-in-hand with the 

NHLPA to make hockey safer. Dating back to 1997, the NHL recognized the dangers of head injuries and took the pro-active step of forming a Joint Concussion 

Committee. Additionally, the NHL also established a Department of Player Safety 

at its headquarters, the first of its kind for any of the professional leagues. 

USA Hockey and USA Football, two organizations that help oversee youth sports 

in the U.S., have followed the lead of their professional counterparts by employing 

a multi-pronged approach to making participation safer. USA Hockey now requires 

coaches to complete an online education module specific to the age group they are 

coaching that includes safety information, concussion education and proper techniques. USA Football, which is endowed by the generosity of the NFL and NFLPA, 

was the first national governing body for any sport to participate in the CDC’s 

‘‘Heads Up Concussion in Youth Sports’’ initiative and has also engaged in providing 

youth with non-tackling alternatives to develop their skills. Additionally, USA Football’s Heads Up Football program encompasses six elements meant to make youth 

football safer, including coach education and concussion recognition. 

Proactive actions like the ones I just mentioned are exactly what parents need in 

order to be assured that everything possible is being done to keep their child safe 

while they are on the field or the ice. 

Researchers have also been hard at work to improve the tools that coaches and 

doctors have at their disposal when treating an athlete. For example, Dr. Dennis 

Molfese, who runs the University of Nebraska’s Center for Brain, Biology and Behavior, located inside the Husker’s football stadium, has been developing an MRI 

Machine that can be used on game day to assess a head injury. This would allow 

the medical staff to determine if a player has suffered a concussion, how severe the 

injury is, and if that player is able to return to the game. Equipment manufacturers 

are also using technology to make innovative changes to helmets, mouth guards, 

footwear and other equipment—all in order to reduce injuries. 

I feel confident saying that given recent rule changes, and the rate which technology is advancing, playing a contact sport today is likely safer than it has been 

in the past. However, we must accept that there is no ‘‘silver bullet.’’ No helmet or 

pad is going to prevent 100 percent of the injuries 100 percent of the time. 

This is why we need to consider a multi-pronged approach aimed at keeping our 

kids safer while still promoting youth participation in sports. This involves listening 

to how leaders like the NFL, NHL, youth leagues and top-tier University researchers are partnering to make progress towards making sports safer. These are the 

types of innovations and paradigm shifts needed to give parents the assurance that 

all possible steps are being taken to improve the safety of their child on the field. 

I would like to thank our panelists for joining us today and being willing to answer our questions. I would especially like to thank Dr. Dennis Molfese and Dr. Tim 

Gay for making the trip to DC from the University of Nebraska at Lincoln. 

Mr. TERRY. And my time is over, so I will recognize the ranking 

member, Jan Schakowsky, from Illinois. 

4 

OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. This is a very important hearing on improving sports safety. I look forward to hearing from all of our witnesses on both panels about their perspectives, experiences, proposals about how to make sports safer for everyone, from children to professional athletes. 

Athletes are continually becoming bigger and faster and stronger, and despite some efforts to make sports safer, much work remains. Three hundred thousand sports-related traumatic brain injuries occur annually in the United States. Sports are the second 

leading cause of traumatic brain injury among people age 15 to 24 

years old, second only to motor vehicle accidents. This is a crisis 

and one this subcommittee should do everything in its power to address. 

We are going to hear today from Ian Heaton, a high school senior, who suffered a severe head injury during a lacrosse game in 

his sophomore year. Despite his impressive recovery, that hit, later 

identified as his third head injury, left him with a limited ability 

to enjoy the types of activities many of his high school students, 

classmates, take for granted. His story should serve as a reminder 

that youth sports injuries can have have devastating and lasting 

consequences. And we will also hear on this panel from Briana 

Scurry, an Olympic and World Cup soccer champion, a goalie, 

forced from the field after a career-ending traumatic brain injury 

almost 4 years ago. Her struggle to overcome the cognitive, physical, and psychological injuries that followed illustrate that even 

our sports heroes are vulnerable to the worst sports injuries. 

Both Ian and Briana should be commended for their courage, and 

I thank you, Briana, in their recoveries and for their willingness 

to testify on this critical issue. 

Dave Duerson, a Pro Bowl and Super Bowl-winning safety, and 

former member of my hometown Chicago Bears, tragically committed suicide just over 3 years ago. In doing so, he shot himself 

in the chest to avoid any impact on his brain, which he asked to 

have donated to medical research in order to allow scientists to 

study the impact of the brain trauma he suffered over his 11-year 

professional career. It was later disclosed that Duerson suffered 

from a ‘‘moderately advanced’’ case of chronic traumatic 

encephalopathy, a disease linked to repeated blows to the head, 

which can result in memory loss, depression, and dementia. 

The Heaton and Scurry stories prove that severe, career-ending 

sports injuries can occur at any level of competition, and the 

Duerson case should make it clear to all of us that the impacts of 

brain trauma go way beyond an athlete’s days on the field and can 

become more severe over time. 

We will also hear today from medical and scientific experts who 

have studied the impacts of brain injuries on athletes of all ages. 

We will hear about the importance of taking athletes off the field 

of play as soon as there is a suspicion of a brain injury, and keeping them off until they are cleared by a responsible and trained individual. 

5 

And finally, we will hear from the NHL, the NFL, and youth 

hockey and football leagues that are responsible for mitigating 

traumatic brain injury in their sports. I hope to learn what changes 

they have implemented, and will implement, to rules, practice 

drills and other aspects of the games that will reduce the risk of 

brain injury moving forward. 

I am not advocating for an end to sports as we know it, or maybe 

not exactly as we know it right now, but I also feel strongly that 

300,000 head injuries per year are too many to overlook. We should 

take reasonable steps to reduce the risk. And I look forward to 

hearing from all of our witnesses. I hope this hearing will help the 

subcommittee to better understand the safety risks in sports, and 

what we can and should be done to limit these risks. 

And I yield back the balance. 

Mr. TERRY. Thank you very much. At this time, recognize the 

vice chairman of the committee, Mr. Lance, from New Jersey. 

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

Mr. LANCE. Thank you very much, Mr. Chairman, and thank you 

for holding this extremely important hearing. I want to thank Dr. 

James Johnston, who will be one of the witnesses, who came to my 

office earlier this morning. Thank you, Dr. Johnston. 

Experts generally agree that a concussion can be classified as a 

brain injury, ranging in seriousness from mild to dramatic. The 

Center for Disease Control states a concussion is caused by a 

bump, a blow or a jolt to the head, or blow to the body that causes 

the head to move quickly. According to the CDC, the sports that 

reported the highest number of traumatic brain injuries were bicycling, football, playground activities, basketball and soccer. 

From 2010 through 2013, the participation rate of children in 

youth soccer and football dropped considerably, and some have 

pointed to the increased risk of TBI’s as a result of participating 

in these sports as a reason for the drop in that participation. 

The increased spotlight on concussions in sports has resulted in 

an increased amount of research in brain injuries, as well as research on how to improve sports equipment in order to prevent 

such injuries from occurring. Collegiate and professional sports 

leagues have implemented standards and revised their rules in 

order to decrease the number of brain injury incidents. The NHL 

has, as has been indicated, has required its players to wear helmets on the ice, and the NFL instituted new standards for evaluating concussions on the sidelines after the league reported an occurrence of 223 concussions in just over 300 games in the 2010 season. 

And State and Federal Governments have also been involved in 

tightening safety standards, and since 2009, all 50 States and the 

District of Columbia have adopted laws protecting youth and high 

school athletes from returning to play too soon after suffering a 

concussion or a potential concussion. 

This hearing will focus on what more can be done to prevent 

brain injuries from occurring in sports, and this is at the youth 

6 

level, the amateur level and at the professional level. And I look 

forward to the testimony of our distinguished panels. 

Thank you, Mr. Chairman. 

Mr. LANCE. I have two and a half minutes remaining. Is there 

any other member on the Republican side who would like to speak 

with an opening statement? 

Mr. TERRY. OK. 

Mr. LANCE. I yield back the balance of my time. 

Mr. TERRY. Especially Missouri. Do they play sports? And on behalf of the Big 10, I want to welcome Rutgers to the Big 10. At this 

time—— 

Mr. LANCE. Thank you very much. 

Mr. TERRY [continuing]. Five minutes to the full ranking member 

of the Energy and Commerce Committee, Mr. Waxman. 

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

Mr. WAXMAN. Thank you very much, Mr. Chairman. 

Decades ago, many thought that head injury was serious only if 

a player was completely knocked out unconscious, and/or suffered 

a severe contusion, after frequent painful blows, even a young athlete could continue to play, but we now have strong indications 

that the effects of repeated brain trauma in sports, even those received during one’s youth, can accumulate with consequences that 

are long-term debilitating and even life-threatening. These consequences can stem from injuries once considered minor, known as 

subconcussive blows, which may not be accompanied by any immediate adverse symptoms. 

Serious psychological and emotional disorders have been documented among former athletes that have suffered repetitive brain 

trauma. Researchers have, a number of times, found evidence of 

the neurodegenerative disease, CTE, when examining the brain tissue of dozens of deceased former NFL players. New imaging technologies have been able to show the metabolic changes in the brain 

associated with concussions and subconcussive blows. 

Brain injuries in sports can occur in a wide variety of situations, 

and different athletes’ brains may respond differently to an injury. 

Sports-related brain injury is a complex matter, requires addressing many interconnected issues, so when the title of this hearing 

suggests we take a multifaceted approach to improve sports safety, 

I could not agree more. 

First, we need more neuroscience research, radiological and longitudinal research methods can lead to earlier, more accurate diagnoses, a better understanding of the risk factors, and maybe better 

treatment options for brain injuries. 

Second, doctors, league associations, coaches, parents, players 

need to work together to establish health regulations, game rules 

and a sporting culture that reflects the seriousness of brain injury, 

and put the athlete’s health first. 

Third, we must address the health and safety risks associated 

with the athletic equipment, and pursue a better understanding of 

how this equipment might be improved. 

7 

Three years ago, Congressman Butterfield and I wrote to the 

then-chairman at the time of the subcommittee and full committee 

chairman, calling for hearings about inadequate testing standards, 

lax reconditioning certifications, economic disparities regarding the 

safety of football helmets used by millions of American athletes. We 

are going to touch on some of those issues today, but I believe those 

issues merit deeper consideration than they are likely to get at today’s hearing, and the subcommittee chairman might consider 

holding separate hearings on these matters. 

I think it is valuable that the National Football League is testifying here today, given recent and ongoing disputes between the 

league and its players on this very topic. However, I believe its 

players organizations should also testify. Unfortunately, the late 

notification of the NFL testifying made it difficult for us to secure 

players’ witness. 

Mr. Chairman, today’s hearing is important. I appreciate the 

subcommittee review of sports-related brain injuries, and I look forward to working together, all of us, on this issue in the months 

ahead. Thank you for holding the hearing, and I look forward to 

the testimony of the witnesses. 

Yield back my time. 

Mr. TERRY. Still have a minute left, if the gentleman from Utah 

wanted to use it. 

Mr. WAXMAN. Well, I might just point out that moving physically 

and conditioning the body is not anywhere near dangerous as subjecting oneself to brain injuries, so I don’t think they are contradictory. 

Mr. TERRY. Yes. It is interesting, but the issue is we want kids 

to go out and play. We want them to join youth leagues. 

Mr. WAXMAN. And we want sports, but we want to make it as 

safe as possible. 

Mr. TERRY. Absolutely. And to use your last 26 seconds, then, 

this is one of those where Jan and I both agreed was necessary. 

So this has been a bipartisan effort. 

So with that, let us move on to our witness panel. And I am 

going to introduce the entire panel now, and then we will start 

with Mr. Daly. So we are blessed to have Mr. William Daly, III, 

Deputy Commissioner of the NHL. Next to him is David Ogrean, 

Executive Director of USA Hockey. Then we have Mr. Jeff Miller, 

Senior Vice President, Player Health and Safety Policy, National 

Football League. Thank you very much for being here. And then 

Scott Hallenbeck, Executive Director, USA Football. Then a face of 

a brain injury, concussions, multiple concussions, within soccer, 

Briana Scurry, a former professional goalkeeper, U.S. Women’s National Soccer Team. In the next panel we will have Ian, who is the 

other face of high-school-level concussions. 

So with that, Mr. Daly, you are now recognized for your 5 minutes. 

8 

STATEMENTS OF WILLIAM L. DALY, DEPUTY COMMISSIONER, 

NATIONAL HOCKEY LEAGUE; DAVE OGREAN, EXECUTIVE DIRECTOR, USA HOCKEY; JEFF MILLER, SENIOR VICE PRESIDENT, HEALTH AND SAFETY POLICY, NATIONAL FOOTBALL 

LEAGUE; SCOTT HALLENBECK EXECUTIVE DIRECTOR, USA 

FOOTBALL; AND BRIANA SCURRY, FORMER PROFESSIONAL 

GOALKEEPER, U.S. WOMEN’S NATIONAL SOCCER TEAM 

STATEMENT OF WILLIAM L. DALY 

Mr. DALY. Thank you. I would like to thank the chairman, the 

ranking member, and the subcommittee members for inviting me 

to testify today regarding the National Hockey League and the 

proactive steps it has taken to promote the health and safety of the 

best professional hockey players in the world. 

As its playing surface is enclosed by boards and glass, making 

it the only major professional sport with no out of bounds, hockey 

is a physical game. At the NHL level—— 

Mr. TERRY. Is your mic on? 

Mr. DALY. It was, yes. 

Mr. TERRY. Just pull it a little lower and closer. 

Mr. DALY. I will bring it closer. At the NHL level, our players 

want it to be physical, and our fans want it to be physical, but importantly, all constituent groups associated with the game also 

want it to be safe. This objective necessarily includes promoting 

safe and responsible play in our game, and the National Hockey 

League, working together with the National Hockey League Players’ Association, has gone to elaborate lengths to do that and will 

continue to do so. 

We are pleased to have this opportunity to share with this subcommittee some of the measures enacted in this pursuit. The National Hockey League was the first major professional sports league 

to launch a comprehensive league-wide program to evaluate players after they incur head injuries. Beginning in 1997, the NHL/ 

NHLPA Concussion Program has required that all players on all 

clubs undergo preseason baseline neuropsychological testing. After 

a player is diagnosed with a concussion, he undergoes post-injury 

neuropsychological testing, and his pre- and post-injury test results 

are compared to determine when the player is safe to return, or returns to neurological baseline, which is a relevant determination in 

the player’s ability to safely return to play. 

Data collected and analyzed pursuant to the NHL/NHLPA Concussion Program confirmed to us early on that neuropsychological 

testing results had added value, and should be taken into account, 

along with player reported symptoms when making return-to-play 

decisions. 

The NHL/NHLPA Concussion Committee also has taken affirmative and proactive steps to issue league-wide protocols regarding 

the diagnosis, management and treatment of concussion. Education 

regarding concussions and, importantly, the issuance of warnings 

to players relating to the risks of returning to play before the recovery from a prior concussion is complete, have been a core component of the NHL/NHLPA Concussion Program since its inception. 

Education is provided regularly to all relevant constituents in our 

9 

league, including our players, club personnel and NHL on-ice officials. 

In addition to enforcing existing playing rules, such as charging, 

crosschecking and high-sticking, and more stringently penalizing 

dangerous contact, several new playing rules have been adopted 

specifically to prohibit involving a player’s head. Our current rule 

specifically prohibits any body contact with an opponent’s head 

when the contact is otherwise avoidable, and the head is the main 

point of contact. Changes this season to adopt the hybrid icing rule, 

and modifications of rules regarding fighting, have further enhanced player safety. With respect to the fighting issue in particular, while it remains a small part of the game, its role is diminishing. Through 75 percent of the 2013–2014 regular seasons, 68 

percent of the games played have been completely free of fighting, 

the highest such percentage since 2005–2006. In addition, the number of major penalties assessed for fighting is down 15 percent from 

last season, and down 31 percent from the 2009–2010 season. 

In this important area, it would be the league’s intention to 

raise, discuss and negotiate any potential playing rule changes regarding fighting directly with the National Hockey League Players’ 

Association. Ultimate enforcement of the playing rules through 

supplementary discipline is in the hands of the Department of 

Player Safety, the first league department of its kind in professional sports. This department monitors every one of our 1,230 regular season games, plus all of our playoff games, and assesses 

every hit, indeed, every play, to ensure the league’s standards for 

safety and responsible play are being adhered to. When the Department determines that the standard has been violated, supplemental discipline is assessed in the form of a suspension or a fine, 

and the Department creates a video that explains to our players 

and our fans why the behavior merited punishment. The cumulative effect of these efforts has begun to change the culture of the 

game in a positive way. As we can see on a nightly basis, players 

avoiding dangerous plays and gratuitous contact that they, no 

doubt, would have engaged in just a few short years ago. 

Since the adoption of the mandatory helmet rule in 1979, the 

NHL, together with the NHLPA, has continued to impose a series 

of additional regulations regarding player equipment relating to 

player safety generally, but also to head injuries more specifically, 

including most recently a rule adopted prior to the start of this season that mandated the use of face shields by all incoming players, 

the effect of which should reduce head injuries generally, in addition to providing enhanced protection for players’ eyes. 

The NHL also has participated in concussion initiatives that extend beyond the NHL, including its representatives’ participation 

at each of the 4 International Concussion and Sport Conferences 

between 2001 and 2012, its support of Federal and State legislative 

initiatives regarding concussions, and the league’s support and assistance in the development of concussion educational programs for 

youth and junior-age hockey players. 

To summarize, while recognizing there is considerable work to be 

done, the National Hockey League has been, and will remain, absolutely committed to promoting the safety of its players. We firmly 

believe it is not only the right thing to do for our players, but it 

10 

is the right thing to do for our business, both in terms of promoting 

participation at the youth hockey level, and in maximizing interest 

by fans and consumers of the sport at the professional level. 

Again, I thank the chairman, the ranking member, and the subcommittee members for your time and invitation to speak to you 

this morning. 

[The prepared statement of Mr. Daly follows:] 

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Mr. TERRY. Thank you. Mr. Ogrean, you are recognized for your 

5 minutes. 

STATEMENT OF DAVE OGREAN 

Mr. OGREAN. Thank you, Chairman Terry, Ranking Member 

Schakowsky, and distinguished members of the subcommittee. It is 

a privilege to be with you today to discuss an issue that is the top 

priority every day at USA Hockey, and that is the safety of our 

participants both on and off the ice. 

We have adapted well to changing environments over time, and 

we have two particular leaders that we wish to thank, and who 

guide a great deal of our decision-making. One is Dr. Mike Stewart, 

our Chief Medical Officer, who is the head of sports medicine at the 

Mayo Clinic in Rochester, Minnesota, the other is Dr. Alan Ashare 

from Saint Elizabeth’s Medical Center in Boston, who is also the 

chair of our Safety and Protective Equipment Committee. That 

committee has been in existence at USA Hockey for 40 years, and 

it is an important group helping to guide our Board in making its 

decisions. 

We have a Risk Management Committee which is concerned with 

the safety of the playing environment and the surrounding area, 

and in 1999, in cooperation with U.S. Figure Skating, we began an 

organization called Serving the American Rinks, or STAR, which is 

essentially a trade and education organization for ice facilities, focusing on a variety of operational aspects, including safety issues 

in rinks. 

In terms of the safety of our participants, we believe we can and 

do positively affect the landscape through 3 primary areas; education, rules and rules enforcement, and risk management. Education related to safety happens on an ongoing basis at USA Hockey, and we utilize many avenues to communicate. We have, very 

fortunately, direct electronic communication with every single 

home, every player, every parent, every official and every coach in 

our organization, through our database. We are constantly in communication with them with educational bulletins and news. Our 

coaches have a huge influence in providing a safe and responsible 

environment, and our coaching education program has long been 

heralded in the amateur sports world as the gold standard for 

coaching education. 

As Congressman Terry referenced, this last year—or, excuse me, 

two seasons ago—we added an online educational module that is 

age-specific in nature, which also contains critical safety information, including concussion education. Officials, obviously, play a 

very important part in how our game is made safe as well, and 

they receive regular evaluation and education electronically, and 

are sent video clips and also access to our national reporting system which tracks penalties, to help us understand and assess behavior trends. We annually mail posters to every ice facility in the 

country to help deliver our messaging, and, over the years, those 

posters have focused on topics including concussion prevention, 

concussion education, playing rules emphases, and our heads-up, 

don’t duck program, to name a few. 

As for rules and rules enforcement, we have modified our rules 

to adapt to the evolving landscape of the game on an ongoing basis, 

21 

from mouth guard and helmet issues to rules aimed at eliminating 

dangerous behavior. Another recent modification in USA Hockey 

came in June of 2011 when our Board voted to change the allowable age for body checking in games from the peewee, or age 11 

and 12 level, up to the bantam age group of 13 and 14. This was 

done despite many voices around the country in opposition to 

change, which nobody seems to like, but research based on both 

athlete development and safety guided our Board decision. It is 

worth noting that 2 years later, Hockey Canada followed our lead. 

Regarding equipment and its impact on safety, USA Hockey took 

a significant step in 1978 when it called for the creation of the 

Hockey Equipment Certification Council, or HECC. HECC’s mission is to seek out, evaluate and select standards and testing procedures for hockey equipment for the purpose of product certification. 

It is very similar to NOCSAE, which a lot of you may be familiar 

with, that football uses in certifying its helmets. It is a completely 

independent body made up of attorneys, doctors, engineers, manufacturers, testers and sportspeople. It validates the manufacturer’s 

certification that the equipment they produce has been tested, and 

meets the requirements of the most appropriate performance 

standards, and it has been an important part of our safety story 

for 35 years. 

Before closing, I would like to share with you briefly our newest 

off-ice safety program called USA Hockey Safe Sport, following the 

lead of the United States Olympic Committee, this is to protect our 

participants and educate on policies regarding hazing zero tolerance, locker room supervision, and abuse of any kind. In the early 

1990s, we were one of the very first youth sports organizations to 

require screening of all adults that have regular access to our 

youth participants. We follow-up on 100 percent of calls we receive 

around the country of alleged abuse, and our 34 affiliate associations each have a volunteer safe sport coordinator that helps us as 

boots on the ground to provide the safest possible environment for 

our participants. 

Our sport has enjoyed tremendous growth in the last 25 years, 

more than doubling in the number of youth players that we have. 

As we continue to provide opportunities for young people, we know 

that in doing so, we have the responsibility to make our game as 

safe as possible, and will only continue to grow if we are successful 

in doing so. 

Thank you. 

[The prepared statement of Mr. Ogrean follows:] 

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Mr. TERRY. Thank you. Mr. Miller, you are recognized for your 

5 minutes. 

STATEMENT OF JEFF MILLER 

Mr. MILLER. Chairman Terry, Ranking Member Schakowsky, 

members of the subcommittee, appreciate the opportunity to testify 

this morning on behalf of the National Football League on an issue 

of great importance to the league, and I commend the committee 

for taking up this issue. 

There is nothing more important to the NFL than the safety of 

our players. Commissioner Goodell has stated repeatedly in the 

past that he spends more time on the health and safety of our sport 

than any other issue that comes before him. 

Football has earned a vital place in the rhythm of American life. 

There are nearly 6 million kids who play tackle or flag football 

across our country, another 1.1 million that play in high school, 

75,000 in college. And so whether it is touch games in our backyards at Thanksgiving, or games played in our local parks by our 

kids, or Friday night high school games, Saturdays with college, or 

hopefully plenty of people watching the NFL on Sundays and Mondays, and occasionally Thursdays, football plays a significant role 

in our lives, and we take that popularity seriously. With it comes 

a great deal of responsibility, and that is one that we embrace. 

We understand the decisions that we make at our level affect 

football at all levels, and probably far beyond that, and so I appreciate the opportunity to share the NFL’s work with the subcommittee on the health and safety of our athletes who play our 

game. 

Now, football has always evolved. The rules have always 

changed, and so I would like to share with the subcommittee a few 

examples of that over the last couple of years, and the impact that 

that has had at our level. 

It has only been a couple of years ago that we changed the kickoff line at the NFL, moving it forward 5 yards. We did that because 

we had identified the kickoff and the kickoff return is the single 

most dangerous play in our sport as related to the number of concussions. So by moving it forward 5 yards, we decreased the number of concussions on that particular play by 40 percent. That was 

in the first year alone, and that number has stayed steady in successive years. 

In addition, for those of you who are fans, you have seen a greater emphasis on eliminating helmet-to-helmet hits in our game, you 

have seen a greater emphasis on eliminating the use of the crown 

of the helmet in our game, and you have seen fines and suspensions, not to mention penalties, as a result of them. And these are 

the sorts of things that we are looking to do to change the culture 

of how our sport is played. We have encouraged players to lower 

their target zones as they tackle, we have emphasized through our 

coaching that there are better ways to go about what they are 

doing, and we have seen the results. In the past year alone, between 2012 and 2013, the NFL has seen a decrease in the number 

of concussions at our level by 13 percent. A decrease in helmet-tohelmet hits causing concussions has been down 23 percent in one 

year alone. Now, that is not a victory, that is a trend, and one that 

28 

we find encouraging, but there is more work to be done as we begin 

to change the culture of the sport as it relates to that. 

And we have added other protocols to our sideline to take care 

of our players. There is one rule that governs us, and that is that 

medical concerns will always trump competitive ones. So we have 

added unaffiliated neurotrauma consultants on the sideline. That 

is a concussion expert in every city to help the team physician 

identify concussions and treat the players. We have added athletic 

trainers in skyboxes for the sole purpose of watching the game, and 

calling down to the sideline if they identify an injury, concussive 

or otherwise, to make sure that the player is attended to appropriately. And we have mandated uniform sideline protocols across 

all 32 of our teams so that everybody is working off the same playbook, and those protocols are based on internationally accepted 

medical guidelines. We would expect nothing less. And we know as 

we change the culture of our sport as it relates to health and safety, we have an impact far beyond. And so let me cite two examples 

of that for the subcommittee. One is our support for USA Football, 

and you will hear from Mr. Hallenbeck in a moment. Their Headsup Program, among their other offerings, are changing the game in 

our parks, in our communities around the country literally as we 

speak. The popularity of these programs, which I won’t steal Scott’s 

thunder on, have been tremendous, and the NFL is a proud supporter of USA Football, and will continue to be in all that they do 

to change the game, and we are proud of his work particularly. 

In addition, the NFL used as inspiration a young child named 

Zackery Lystedt who was a 13-year-old youth football player in 

Washington State several years ago who suffered catastrophic injuries playing his sport. He was returned to play too soon after suffering a concussion. And Zackery still struggles with the challenges 

that come from that. His advocates were able to pass a Youth Concussion Law in Washington State which our commissioner said we 

will replicate in all 50 States around this country to make sure 

that all youth sports, not just football, are played more safely, that 

kids and their coaches are aware of the risks of concussion, that 

they are removed from play should it appear that they suffer concussion, and most importantly, not return to play until a medical 

professional has cleared them. Just this past month, we are proud 

to say that the fiftieth State passed that law, and now the NFL 

isn’t solely responsible for that work, but we are happy to lead and 

to be in many of these States to get this done. 

And as my time expires, let me just mention two other quick 

components. We have been proud to work with the CDC promoting 

concussion materials that have gone out to millions of kids, posters 

in locker rooms, and to fund much of their Heads-up Program. We 

have also invested tens of millions of dollars in research; $30 million with the NIH, which is the largest grant that the NFL had 

ever given, and the first $12 million of that has gone out already 

to study chronic traumatic encephalopathy. In addition, we are 

very proud of a $60 million effort we have with General Electric 

and Under Armour, both to improve the diagnosis and prognosis of 

concussion by developing better tools, and then secondly to find 

better ways to protect against concussion in the first place. These 

29 

are ongoing issues and ones that we think are going to yield significant successes in a short time. 

So I apologize for exceeding my limit, Mr. Chairman, but I appreciate the time. 

[The prepared statement of Mr. Miller follows:] 

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Mr. TERRY. At this time, Mr. Hallenbeck, you are recognized for 

your 5 minutes. 

STATEMENT OF SCOTT HALLENBECK 

Mr. HALLENBECK. Chairman Terry and members of the committee, thank you for the invitation to testify. 

USA Football creates and directs programs and resources that 

establish important standards rooted in education for youth and 

high school football. We stand with experts in medicine, child advocacy and sport who believe that education changes behavior for the 

better. This is precisely what we are seeing through our Heads Up 

Football program, which is already benefiting more than 25 percent 

of youth football leagues across the country in its first 14 months, 

and we expect to double that this year. 

We advance safety through evidence-based studies by independent experts, we also lead fun and dynamic instructional football initiatives for young players, as well as a national non-contact 

flag football program. More on these and other aspects of our work 

resides in my written testimony. The remainder of my time will be 

showing a video of how Heads Up Football High School Pilot Program is improving player safety within the Fairfax County Public 

School system, which earned high marks from parents, coaches, administrators in its first season. It paid close attention to hearing 

from the athletic directors and the principals and the superintendents of the schools on how this program is making a difference. 

[Video shown.] 

[The prepared statement of Mr. Hallenbeck follows:] 

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Mr. TERRY. Thank you. Now Briana Scurry, appreciate you being 

here, and you are recognized for 5 minutes. 

STATEMENT OF BRIANA SCURRY 

Ms. SCURRY. Thank you very much. 

Yes, my name is Briana Scurry and I am 42 years old. I served 

as a starting goalkeeper for the United States Women’s National 

Soccer Team from the years 1994 to 2008. During that time, I 

helped lead the team in winning two Olympic gold medals in 1996 

Atlanta games and 2004 Athens, and played 173 international 

games over 15 years for the United States, which is a record among 

female goalkeepers. 

In the summer of 1999, my 20 amazing teammates and I captured the hearts of America by beating China in a penalty kick 

shootout live in front of 90,000 screaming fans at the Rose Bowl 

in Pasadena, California. I was the one that made the single save 

during the penalty kicks before Brandi Chastain took off her shirt. 

Yes, now I will be many of you recall exactly where you were at 

that moment. It was the kind of event that transforms lives forever 

for the better. My passion and my mission was soccer. My ultimate 

reward was living my dreams and inspiring the dreams of countless others. 

Today, I am here before you to share my new mission with you. 

My new mission is to provide a new face and voice to those who 

have had and may suffer the long and difficult recovery of a devastating traumatic brain injury and concussion. 

My life story reads like a script from Oprah Winfrey’s Where Are 

They Now. Like many of Oprah’s guests, I too have been lost in 

deep, dark places with my face in the dirt, and have only recently 

begun to claw my way back to my life. 

On April 25, 2010, my life changed forever. During that day, I 

played a women’s professional game against the Philadelphia Independence in Philadelphia, and in that game, I suffered a traumatic 

brain injury that abruptly ended my beloved soccer career. That 

was nearly 4 years ago. 

I struggled with intense piercing headaches that were so bad 

that, by the evening, it was all I could do not to cry myself to sleep. 

I had to take naps on a daily basis just because my sleep was so 

disrupted. I couldn’t concentrate and I was very moody. I felt completely disconnected from everything and everyone. I was anxious 

and depressed every day, and I wondered if I would ever get better. 

I recently moved to DC to have bilateral occipital nerve surgery 

at Georgetown to eliminate severe headaches that plagued me 

daily. Fortunately for me, the surgery appears to have worked, 

however, I am still being treated for symptoms such as lack of concentration, balance issues, memory loss, anxiety and depression. I 

have purposefully and intentionally had my concussion recovery 

story documented by media outlets, such as the USA Today, The 

Washington Post and Brainline.org, in order to bring attention and 

a ray of hope to those suffering from TBI like me. 

In September, I was alarmed to learn that the number of reported cases of concussion in soccer was second highest in the 

United States, with only American football having more cases. Additionally, a recent article published in November stated that one 

53 

of two female youth soccer players will suffer a concussion while 

playing. I feel the numbers of reported cases are likely understated, 

and didn’t designate those who suffered multiple concussions like 

I have. Statistics like these have solidified my urgency of purpose 

to shed light on the high frequency of concussions in youth, and the 

devastating emotional toll that prolonged symptoms often cause, 

yet are too frequently dismissed. 

I sincerely hope that my presence here today will inspire increased awareness, understanding and assistance to help the thousands of young TBI sufferers across this country. 

I thank you all for allowing me to give testimony. I am grateful 

and humbled to have been invited to do so. Thank you. 

[The prepared statement of Ms. Scurry follows:] 

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Mr. TERRY. Thank you very much. And that was powerful. 

So this is our opportunity now, each of us have 5 minutes to ask 

you questions. 

So, Ms. Scurry, let me ask you this one. I too was shocked to 

learn that soccer had the second most concussions, which is a really dominant youth sport. Are you seeing changes within soccer and, 

unlike there is an obvious top-to-bottom connection that we heard 

from the NHL and the NFL, is anything like that occurring in soccer? 

Ms. SCURRY. Thank you for the question. I too was very surprised to read that statistic. I think it is so high in part because 

the explosion of players that are playing soccer now in the last 10 

years. 

I am not finding that soccer has completely grasped the alarm 

or the situation like USA Football, USA Hockey have. Part of the 

reason I am here today is to shed light that soccer too should be 

instrumenting different protocol like NHL and the NFL are, and 

hopefully the governing body for soccer, which is U.S. Soccer, will 

start to understand that our great sport is in danger of having too 

many head injuries, and that something does need to be done about 

it, and something needs to be instrumented. 

Mr. TERRY. All right. And thank you, and I think your assessment of the game that you played, and winning that championship 

over China, we all, at least I, remember that one event. 

Ms. SCURRY. Thank you. 

Mr. TERRY. It was a great game. 

Now, to Mr. Miller, the NFL has taken, I think, seriously, undertaken effort to get the so-called return to play guidelines adopted 

at all State levels. Can you tell us more about what the guidelines 

are and how they are developed? 

Mr. MILLER. Sure, and thank you for the question. 

The Zackery Lystedt Law, which is the model law that was 

passed out in Washington State, contained three primary elements, 

the first of which would be that parents and their kids would have 

to sign off on an education sheet a notification about the risks, 

signs and symptoms, related to concussion before they were allowed to participate. The second was that a child who appeared to 

have suffered a head injury must be removed from play immediately, in other words, the coaches were asked to act conservatively. And finally, that a licensed medical Provider who has a 

training in the management and evaluation of concussions has to 

return every child to play. And that part was done in large part 

to eliminate the danger that Zackery faced when he returned to 

play in the same game too soon. 

And all these laws are very new, and so I know that there are 

academics who are studying them to see their success, but I just 

know, as one anecdote in Washington State, the one that had the 

first one, in the years after the Lystedt Law was passed, they 

didn’t see a single brain injury, in other words, blood on the brain 

of any single football player in the State of Washington, and they 

had normally seen three or four significant brain injuries on an annual basis, and those were eliminated. 

Now, that is anecdotal and more work needs to be done. And I 

commend those States who are going back and making their laws 

56 

more strict, because they need to be expanded to the youth level. 

Many of them are high school only. They need to be expanded to 

recreational spaces so it is not just school-based sports. And there 

is more that can be done, and there are those that are doing that, 

and we are happy to work with those. 

Mr. TERRY. Thank you. Mr. Ogrean, have you seen a demonstrable reduction in concussion incidents at USA Hockey after implementing new techniques? 

Mr. OGREAN. We do not have the same statistical data that I 

think USA Football has invested in, and, in fact, we are talking to 

DataList, the same company, to do that sort of thing. 

Any concussions are too many concussions. What we have focused on is research, education and rules enforcement. The statement was made in someone’s opening remarks regarding the culture of certain sports, and obviously, we know that a lot of sports 

at the youth level suffer from a misplaced, you know, macho attitude. A lot of coaches think they are coaching at the professional 

level, and they are not. And so changing that culture is very, very 

important. We have been very, very strict about return to play 

rules, and as Scott used the phrase earlier this morning that I appreciate very much, and we adopt the same thing, when in doubt, 

sit them out. And I think when you are talking about a grassroots 

sport, in our case, we have 350,000 youth players in 2,500 programs, and that equates to about 25,000 teams, one of our big challenges is quality control. You can’t get everybody to act the same 

way or to think the same way, but we do know, I think because 

of our emphasis on preventing head injuries, and what to do with 

them, how to recognize them, how to treat them, how to respond 

to them, and making sure the return to play decision is a medical 

decision and not a coach’s decision, that the number is dropping. 

Mr. TERRY. Great. My time is over. And so the Ranking Member, 

Jan Schakowsky, you are recognized for your 5 minutes. 

Ms. SCHAKOWSKY. Briana, my granddaughter, has played AYSO 

soccer since the first time that she could. Now she is on a traveling 

team in high school. She is 16, so I am very concerned about what 

you are saying, and even more concerned now after you are saying 

that soccer actually seems to lag behind other sports. And there 

have also been studies that have compared the rates of reported 

concussions for male and female athletes that tend to show that female athletes actually have a higher rate of reported concussions 

than male athletes in the same sports. 

So what would you say that we need to do immediately? I mean 

I really do worry about her now and what could happen, so what 

would your advice be to female athletes, female soccer players, and 

to those who coach and treat them? 

Ms. SCURRY. I too find that statistic very alarming. I think one 

of the things that needs to occur with soccer is officials and referees, coaches need to take their heads out of the sand a little bit 

and realize that this is something that is plaguing our sport as 

well. And the video that was played by Mr. Hallenbeck earlier was 

a fantastic example of where to start. You start with the coaches. 

You teach the coaches the proper way to teach the players how to 

head, and do certain drills to make sure that the coaches know how 

to teach it instead of just letting players run around out there, and 

57 

let the ball head them; instead, teach them how to head the ball, 

and also improve the strength of the neck muscles. For females, it 

seems to be part of the issue is they are not as strong as the male 

counterparts in heading. And so that needs to occur. And there just 

needs to be an understanding and an education of what you are 

looking for when a head injury does occur. 

Ms. SCHAKOWSKY. Let me ask you a question. I don’t know if soccer is the only sport where you quite deliberately use the head. 

Ms. SCURRY. Right. 

Ms. SCHAKOWSKY. Is that an inherent problem? 

Ms. SCURRY. I don’t necessarily think it is an inherent problem—— 

Ms. SCHAKOWSKY. Right. 

Ms. SCURRY [continuing]. But, obviously, I think that scenario, 

when there is a ball in the air you are going to head, that there 

is something highly probable that could happen, but I think if you 

teach it properly, you are going to have those head injuries no matter what you do, just like they said, when you play the sport, you 

are going to have injuries that happen, but I think that certain 

things that happen during a heading situation isn’t the only reason 

or only time when concussions occur. 

Mine in particular happened when I was playing in the goal, 

going for a low ball from my left, the player came in from the right 

and hit me in the side of my head with her knee. 

Ms. SCHAKOWSKY. Uh-huh. 

Ms. SCURRY. And that has nothing to do with heading—— 

Ms. SCHAKOWSKY. No. 

Ms. SCURRY [continuing]. At all, you know. Head to knee, head 

to foot, head to post isn’t part of that. 

Ms. SCHAKOWSKY. Well, I would love to get your advice as we 

move forward, and anything that I can do outside of this body, because I certainly—— 

Ms. SCURRY. Fantastic. 

Ms. SCHAKOWSKY [continuing]. Worry about my granddaughter. 

Mr. Miller, I wanted to ask you a question. Retired NFL players 

face some of the most serious health challenges of any sport, yet 

benefits for former players are not on a par with Major League 

Baseball or the National Basketball Association, despite the fact 

that the NFL has more than $9 billion in annual revenue. 

So yes or no, does the NFL yet provide lifetime health insurance 

for former players who did not play under the current collective 

bargaining agreement? 

Mr. MILLER. No. The players are able to continue their medical 

coverage when they leave the game, but they are not provided lifetime medical coverage. 

In the most recent collective bargaining agreement with our 

Players Association, there were in excess of $600 million that went 

to the players who played pre-1993, and added pensions and benefits. All of our programs are collectively bargained with our Players 

Association, and so I think during each iteration of our collective 

bargaining agreements, you have seen changes and improvements 

made, excuse me, to the programs for retired players including this 

year, for example, this past CBA, for example. A neurocognitive 

program, screening program—— 

58 

Ms. SCHAKOWSKY. Well, I understand—— 

Mr. MILLER [continuing]. That provides opportunities—— 

Ms. SCHAKOWSKY [continuing]. But professional baseball and professional basketball do provide lifetime health insurance for former 

players. And while I understand the NFL’s ADA Plan, what could 

be the reason to not provide lifetime health insurance for former 

players? 

Mr. MILLER. Well, like I mentioned, all of our programs, all of 

our benefits, and all of the policies are collectively bargained with 

the Players Association, and so the improvements that we have 

seen as far as care for retired players, whether they be the ADA 

Plan, as you mentioned, which accounts for any player who suffers 

from a diagnosis of dementia, neurocognitive benefits, which help 

players’ joint and hip replacements, all of those sorts of things are 

improvements, and are made available to players should they suffer from those issues, in addition to a number of other practices 

and programs, including help lines and our Player Care Foundation, the Players Association has additional programs to help players who are in need at little or no cost, and those programs exist 

today. 

Ms. SCHAKOWSKY. I yield back. 

Mr. TERRY. Mr. Lance, you are recognized for 5 minutes. 

Mr. LANCE. Thank you very much, Mr. Chairman. 

Mr. Miller, the changes that you have made in recent years, the 

rules change, the increased penalties, suspensions for rule violations, reducing full contact practice days, can you share with the 

committee data that you have that this, I hope, has had a positive 

impact on concussion incidents that might encourage leaders at 

other levels of football? 

Mr. MILLER. Absolutely. We are happy to share with the committee, you know, some greater information than I can offer in my 

oral testimony. 

Mr. LANCE. Certainly. 

Mr. MILLER. But the most interesting number from my perspective is when you count up the number of all the concussions that 

were diagnosed in games and practices, preseason in preseason 

practices, and postseason in postseason practices, you see a 13 percent decrease year over year. And—— 

Mr. LANCE. Thirteen percent each year? Year over—— 

Mr. MILLER. Thirteen percent between 2012 and ’13. 

Mr. LANCE. Very good. 

Mr. MILLER. And the emphasis has been on eliminating the use 

of the head in the game, and specifically helmet-to-helmet hits, 

which are a significant cause of the injury. And in those circumstances that we have been able to identify where two helmets 

collide, we have seen a decrease in the number of concussions by 

that cause by 23 percent in the past year. 

There is a lot more work to be done, and those numbers could 

change year over year. I don’t think anybody should rely upon oneyear data as some sort of conclusion, but I am happy to go into that 

further with the committee if you would like to see more of the information. 

Mr. LANCE. Thank you. I think we would, and this is, of course, 

very helpful, and I hope that the improvements continue. 

59 

Mr. Hallenbeck, I believe your testimony indicated that 15 high 

schools in 10 districts participate in your pilot program last year, 

and that you are anticipating 500 to 1,000 will participate this fall. 

And, of course, I would imagine high school football is the football 

that most of us have experience, either through ourselves or 

through a child, and in my case, a son, and this is part of the 

American tradition. 

What are your plans for getting more school football programs at 

the high school level to participate, and what does your outreach 

entail, and how do schools across the country learn about your program? I think the purpose of this hearing is multifaceted, and one 

of the purposes, I would hope, is to inform high schools across the 

country about your program, as the video indicated, occurs here, 

next-door in northern Virginia? 

Mr. HALLENBECK. Thank you. So first of all, one of the common 

themes we are hearing, of course, is inconsistency, and football 

probably is the most fragmented of all used sports, and even at the 

high school level, there are significant challenges there. So what we 

are trying to strive for through this Heads Up Football program is 

consistent teaching, consistent teaching of technique, consistent 

teaching of terminology, and now getting out to the staunchly independent youth programs as well as now high school programs, the 

good news is they are actually being responsive. If it is their superintendents, if there are principals, their athletic directors, they are 

being asked, as it was mentioned in the video, ‘‘What are you doing 

about this?’’ 

Mr. LANCE. And you are doing the asking, or the parents and 

PTAs are doing the asking? 

Mr. HALLENBECK. It is a combination. We are talking to State associations, high school State associations, we are talking to coaches’ 

associations, we are talking directly to coaches, we are working 

with athletic directors, we are working with parent groups, national PTA is involved, we are looking at every conceivable channel 

to communicate this program and the importance of changing behavior. And what I am sharing is there has been a very positive 

response. 

That video by itself, and really the reason I decided to show it, 

has been incredibly influential. In addition, we now have the Big 

10, the Pac-12, the Big 12, the ACC, we will eventually have the 

NCAA, we will have all college conferences involved, every one of 

their coaches will be involved, with PSAs and things of that nature 

that help influence high school coaches and high school programs 

to embrace the Heads Up Football program and help change behavior. 

Mr. LANCE. Thank you. Let me say that if there is one message 

I wish to leave this morning in my 5 minutes of questioning is that 

I would hope that all of those involved at your level of football 

would examine what you are suggesting, because after all, that 

touches virtually all of the American people, and I commend the 

panel for its testimony. 

Thank you, Mr. Chairman. 

Mr. TERRY. Thank you, Mr. Lance. And I just editorialize, that 

is why we have NHL Youth Hockey, NFL Youth Football, is because it does seem that it trickles down. Whatever is said at the 

60 

top, then it gets pushed down to the youth, and so that was by design. 

The gentleman from Utah is now recognized for your 5 minutes. 

Mr. MATHESON. Well, thank you, Mr. Terry. 

I first want to echo something that Mr. Waxman said in his 

opening statement. It may sound obvious but I think it is important that we acknowledge. This is a complicated issue. There are 

a lot of complexities to this, there is a lot we don’t know about 

brain science, and I think we all could agree that the notion that 

this is an issue that merits significant investment and research is 

really something beyond even concussions in sports. We have traumatic brain injury in terms of our soldiers in the field. This is a 

really important issue that is complicated, and we ought to make 

sure we approach it in a thoughtful and comprehensive way, so, 

Mr. Chairman, thank you for scheduling this hearing today. 

I was going to ask Mr. Miller, without taking too long, because 

this is an open-ended question, but could you kind of walk us 

through the steps, as information and research has brought more 

knowledge to the NFL, how has the league responded, and how 

have you positioned yourself on these issues to address the issues 

of concussions? And just if you could walk us through some of the 

history of how it has evolved within your organization. 

Mr. MILLER. Yes, I am happy to do it, and thank you for the 

question. 

I think the point that you made that the science has evolved—— 

Mr. MATHESON. Um-hum. 

Mr. MILLER [continuing]. On neurological issues, certainly 

neurodegenerative disease, is one that the second panel, where 

there is a terrific expert lineup, can talk to, but we rely on the outside advice of very well known, well respected, probably internationally known neuroscientists to advise us as to what the state 

of the science is, and how best to go about changing out game to 

reflect that. And so that is how we ended up creating a unified concussion protocol and return to play protocol for our sideline. That 

is how we ended up with additional concussion experts on the sideline. This is based on the advice of outsiders who tell us this is the 

best way to handle your players, this is the best way to treat the 

game, and if you want a culture of safety, this is what you would 

do, and we follow their advice strictly and meet with them very frequently. 

Mr. MATHESON. All right. And I notice your title is Senior Vice 

President of Health and Safety Policy. That has got to be a position 

that didn’t exist 20 years ago, I bet? 

Mr. MILLER. It did not exist 20 years ago—— 

Mr. MATHESON. Yes, so—— 

Mr. MILLER [continuing]. And I am proud to be in that role, and 

it is an exciting one. 

Mr. MATHESON. I know this hearing is concussions, but since you 

are here, I have to ask you one other question that may be a little 

different topic. 

Over the last few years, I have communicated with the NFL 

about my concerns about the issue of human growth hormone testing, and I know that is something that was raised in the last collective bargaining agreement effort, and there is an agreement to 

61 

agree later, but that hadn’t always come together as much, and I 

know this is something that is important to the league. 

Can you give us an update on what is going on on testing for 

human growth hormone? 

Mr. MILLER. Sure. We appreciate the question. 

Unfortunately, we don’t have human growth hormone testing—— 

Mr. MATHESON. Right. 

Mr. MILLER [continuing]. Yet. The league has been ready, able, 

willing to pursue it, as you mentioned, since it was agreed upon in 

the collective bargaining agreement. Unfortunately, our Players Association has thrown up obstacles—probably fair to say, from our 

perspective, excuses—for a period of time. And I think the testing 

goes to the integrity of the game, certainly. It also goes to the 

health and safety of the sport. 

Mr. MATHESON. Yes. 

Mr. MILLER. You don’t know where this stuff is coming from. You 

don’t know who is giving it to a player or players, and you don’t 

know what they are putting in their bodies, and that is dangerous 

and it is also the wrong example to set. And so this is an important 

issue for us, and one that we are sorry has not gotten accomplished 

yet. 

Mr. MATHESON. Well, that is an important issue to me, and that 

is why I wanted to raise it. I know that it is not this topic of this 

hearing, Mr. Chairman, but since he was here, I had to ask the 

question. 

Ms. SCHAKOWSKY. No, but if the gentleman will yield just—— 

Mr. MATHESON. Yes, I will yield. 

Ms. SCHAKOWSKY [continuing]. For one sentence. I think that is 

why we wanted to have the Players Association here too because, 

you know, that was a pretty strong criticism that you just made. 

It would be nice to have had the players as well to respond. 

Mr. TERRY. Well, I will have to now interject. They were asked 

and they declined. 

Ms. SCHAKOWSKY. Yesterday. 

Mr. TERRY. No. 

Mr. MATHESON. Well, anyway—— 

Mr. TERRY. That is not accurate. 

Mr. MATHESON. Well—— 

Mr. TERRY. They were contacted before yesterday—— 

Mr. MATHESON. I want to reclaim my time—— 

Mr. TERRY [continuing]. And they still rejected. 

Mr. MATHESON [continuing]. For one more question though, if I 

can. I have one more question for you. Where do you see things 

going? I know when you try to crystal ball, it is dangerous because 

you never know, but where do see things going in the next 5, 10, 

20 years in terms of where technology is going to take us? Do you 

have some things about looking out on the horizon that we can be 

looking forward to? 

Mr. MILLER. Yes, I will give you a specific example. As part of 

the scientific research that we entered into with GE, the world’s 

leader in diagnostics, we set aside what we call innovation challenges, two $10 million pots of money. The first was to promote 

new ideas on how to better diagnose concussions. There aren’t any 

objective tests now. They are all subjective analyses. 

62 

Mr. MATHESON. Right. 

Mr. MILLER. And we had people from 27 different countries 

around the world offer ideas. We eventually rewarded 16 of them 

so far, biomarkers, blood tests, these sorts of things. And then in 

addition, we just completed another challenge that echoes around 

protective ideas, how to protect the brain better. We had more than 

40,000 people from 110 countries around the world visit the Web 

site. 

Mr. MATHESON. Wow. 

Mr. MILLER. We had people from 19 different countries offer 

ideas on new protective equipment, and we are reviewing those 

now. And I think that because there is a lot more attention paid 

to this, and hopefully we are one of the actors that are catalyzing 

the science, that you are going to see changes in all of these places 

relatively soon. 

Mr. MATHESON. OK. Appreciate that. 

Mr. Chairman, my time is up so I will yield back. 

Mr. TERRY. Thank you. The gentleman from Kentucky is now 

recognized for 5 minutes. 

Mr. GUTHRIE. Thank you, Mr. Chairman. Thank you for being 

here. And, Ms. Scurry, thank you for being here. That, quite honestly, might have been the only soccer game I have ever watched 

from top to finish. It was—— 

Ms. SCURRY. Thanks a lot. 

Mr. GUTHRIE [continuing]. About the time that my daughter was 

interested in soccer, so we were watching it—— 

Mr. TERRY. No pun intended with the top. 

Mr. GUTHRIE. Top to—OK, no pun intended. That went over my 

head, I am sorry. 

But what a great sporting event, and it is one of the great moments, and to be part of that is something special. And I think it 

was special because it was just so much America. It was youthful, 

you were underdogs, you were grit, determined, and you brought 

up Brandi Chastain, not I, and maybe a little exuberance, but it 

was a great moment, and I appreciate you doing that and sharing. 

But I played high school football. That is my claim to athletic 

prowess, I guess, but we practiced in August. I remember one time, 

in the south, 90-something degrees, and we are all running water 

breaks, we run to the water break and some smart aleck kicks another guy’s foot so he falls, knocks all the water over. So the coach 

says, well, if you guys don’t know how to handle that, we are just 

not going to have water today. So that was over 30 years ago, and 

that would never happen anywhere today. There was actually in 

Louisville a young man who passed away on a football field, and 

the coach went to trial over it, and turned out he wasn’t convicted 

but—so I think the awareness and, you know, stuff like what I described in my youth would never happen on a football field anywhere today, or at least I hope it wouldn’t, but we still have these 

injuries. And I think, Ms. Scurry, you talked about your injury 

being—it wasn’t heading, it wasn’t changing tactics, it was just— 

in soccer you are wearing cleats and short pants and a shirt, and 

somebody hits you in the side of the head with their knee—— 

Ms. SCURRY. Right. 

63 

Mr. GUTHRIE [continuing]. And when you look at, I watch a lot 

of football, of course, then they will have targeting, you know, if 

you are in college football, you are ejected from the game for targeting. But a lot of the injuries you will see, if the quarterback gets 

knocked down and somebody runs and their knee hits them on the 

side of the head. And I don’t know how you change those—and how 

do you deal with that kind of—I know you are trying to do the 

techniques and tackling and not heading the ball the right way, 

but just the incidental things that happen because you are playing 

a sport that you are going 100 miles an hour. Do you have any 

comments on that, Ms. Scurry? 

Ms. SCURRY. Yes, well, thanks for the question. 

That is very relevant, actually, because my hit, when I watched 

it actually last night again on video, it doesn’t seem to be a hit that 

would have taken me out of the game. As it was, I got hit and then 

there were a few minutes later before I actually ended up coming 

out. 

Mr. GUTHRIE. Wow. 

Ms. SCURRY. There wasn’t even a foul called, actually. So that is 

part of the problem, right? Sometimes a hit is a glancing blow, and 

it doesn’t even really seem to be anything that is a big deal, but 

I think for me, my main focus is what is done after a hit occurs. 

And to keep children and young players off the pitch after a blow 

occurs to assess them, and then determine whether they are ready 

to go return to play or not. I think that is the key for me and why 

I am speaking out about this, because I have been around the 

country talking to different organizations, and I am finding that 

kids are getting concussions, five, six, seven, in a very short period 

of time, because they are returning to play too soon, and that is 

where I think a lot of the awareness and education can help. 

Mr. GUTHRIE. Well, thank you. 

And, Mr. Miller, with that, you should do everything you can to 

stop the head-to-head and so forth, but it seems, because they will 

play them on TV over and over—this is when somebody gets injured and they are out, like a knee of the lineman hits, somebody 

like Jon Runyan hits the side of somebody else’s head—I mean, it 

is just incidental, but I guess you are right, you can’t really prevent 

that from happening, but it is how you react to how that happens. 

Is that—— 

Mr. MILLER. Well, I think that is right. One of the recommendations made by the Fourth International Concussion Conference in 

Zurich was to look at the playing rules of the game. And in our 

case, we have done that, and I know other sports have done that 

as well, so you create the best possible situation. 

Mr. GUTHRIE. Um-hum. 

Mr. MILLER. In a contact sport, there will be injuries, and there 

will be, you know, hits to the head, and those problems will occur. 

And so where that happens, we want to make sure that we are 

treating them appropriately, and so that is where the focus shifts 

from prevention to appropriate treatment. 

Mr. GUTHRIE. Well, thank you. And I am about out of time. I just 

want to say, Ms. Scurry, I was sitting on the edge of the couch, 

leaning and moving as they were shooting against you, and hopeVerDate Mar 15 2010 15:08 Jul 22, 2015 Jkt 037690 PO 00000 Frm 00067 Fmt 6633 Sfmt 6633 F:\113THCONGRESS\113128SPORTSSAFETYASKOK060515\113128SPORTSSAFETYPDF
64 

fully you felt my assistance and were able to help us both together 

win one for our team, right? 

Ms. SCURRY. Absolutely. 

Mr. GUTHRIE. Thank you very much. And I yield back, Mr. 

Chairman. Very good job and I am glad to meet you. 

Ms. SCURRY. Thank you. You too. 

Mr. TERRY. Thank you, Mr. Guthrie. Now the gentleman from 

Maryland is recognized for 5 minutes. 

Mr. SARBANES. Thank you, Mr. Chairman, and thanks for the 

hearing, and thanks to our panel. 

Mr. Hallenbeck, I had a quick question about whether the school 

districts that you have been working with that have been implementing this, has that affected the like liability policies that they 

maintain as a jurisdiction? In other words, is there any trend towards they may be getting pushed by the insurance industry, for 

example? So in other words, insurer would say, well, previously, I 

would have provided liability coverage to your school district based 

on these measures or assurances that the district mad with respect 

to how it is conducting its sports program, but now that there is 

this program that enhances the safety of students and young people, we want to see that you have implemented that in your district 

or else we are not going to provide the policy coverage, or we are 

going to charge you a higher premium. I mean you can look at it 

the other way. You get a discount off of your premium as a school 

district because you have implemented these kinds of measures. 

And I ask that because I think that increased awareness of some 

of the risks from these sports injuries may lead to pressure in 

terms of liability on school districts. And you will get some that 

may choose, based on the premium that gets charged, to push the 

program out because they don’t want the liability that comes with 

it. 

So I was just curious whether you are aware of that kind of effect 

from the program, or more generally aware of kind of how the liability concerns intersect with some of these safety efforts that are 

underway. 

Mr. HALLENBECK. Thank you for the question. 

At the high school level, we are literally on the front, you know, 

one-yard line marching down the field. And I will mention that we 

are having very positive conversations with the State of Maryland 

right now about participating in Heads Up Football across the entire State. 

So we have a lot to do there. We have not seen anything from 

a liability concern, insurance concern. With Fairfax County, we 

worked very closely with all their schools and their school district 

about those issues, but they told us, and we checked ourselves, 

they felt they had the appropriate coverage. However, to your 

point, at the youth level, we are absolutely seeing the insurance industry at large, and really the largest provider of casualty and liability insurance, step forward and actually stated that if youth 

football leagues participate in the Heads Up Football program, they 

would receive a discounted program, and a more comprehensive 

coverage. So we are absolutely seeing a positive response by the insurance industry, which, of course, has its merits. 

Mr. SARBANES. Thank you. I yield back. 

65 

Mr. TERRY. Mr. Ogrean, are there any insurance liability issues 

at USA Hockey? 

Mr. OGREAN. Yes, Mr. Chairman, there are plenty of insurance 

liabilities, and I think unlike USA Football, for example, which is 

much more decentralized than are we, our participants are all insured by us as a national organization. So whether it is player accident insurance or whether it is catastrophic insurance, whether it 

is liability and even D and O for all of our leagues, all of that is 

part of what our members pay us a membership fee for. 

Those claims, or those premiums, rather, are obviously based 

upon the number of claims. And so that is another business reason 

why it is in all of our best interests to try to come up with every 

technique, every practice, every policy that we possibly can to make 

our game safer. The number one reason, of course, is the safety of 

the human beings playing our sport, but there are good business 

reasons for all of us to want to do everything possible to make the 

game safer. 

Mr. TERRY. Thank you. 

Mr. Kinzinger, you are recognized for 5 minutes. 

Mr. KINZINGER. Thank you, Mr. Chairman. Thank you for your 

leadership in holding this hearing, and to all of you, thank you for 

being here and bearing through a bunch of politicians. I appreciate 

it. 

I appreciate the diverse panel that has gathered here, and the 

important insights you guys are able to provide on the prevalence 

of concussions in sports. 

According to the CDC, 175,000 sports-related concussions impact 

youth athletes each year, and I think today’s hearing has been very 

constructive in helping us to move forward on understanding that 

and alleviating it. 

I have read much about the legislative action taken across the 

United States to pass concussion laws. In my home State of Illinois, similar legislation was passed in 2011 to require that education boards throughout the State work with the Illinois High 

School Association to adopt guidelines that raise awareness of concussion symptoms, and ensure students receive proper treatment 

before returning to the team. In addition, it is encouraging that 

professional sports leagues and teams are taking steps to address 

concussions not only in their own ranks, but also working with collages and youth leagues to bring attention to the issue. 

Last year, the Chicago Bears—go Bears—kicked off a pilot program to provide certified athletic trainers at three high school stadiums during Chicago public school football games. Such high profile initiatives are important to combatting this issue, and I applaud the Chicago Bears for their leadership. 

Again, I find these steps to be promising, but we are still confronted with staggering numbers of youth being impacted by 

sports-related concussions. 

I would like to ask just a few questions, maybe not take all 5 

minutes, maybe I will. 

Let us talk about the equipment issue. I will ask each of you to 

respond. 

Where are we at today in terms of what kind of equipment is 

being utilized to protect, versus maybe where we were a few years 

66 

ago, what kind of advances are yet to be made that you think we 

are on the cusp of making or that we should make, and then is this 

backed by medical science? Is that what is going into this idea? 

So, Mr. Daly, I will start with you and I guess whatever you 

want to put into that subject would be great. 

Mr. DALY. Well, thank you for the question. 

It is a very important issue, obviously. The equipment issue is 

a very important issue, and something we are focused on jointly 

with our Players’ Association. We have a protective equipment subcommittee that is part of our Joint Health and Safety Committee. 

So we look at all aspects of equipment and, particularly as it relates to head injuries, how we can improve equipment, and perhaps 

reduce the amount of head injuries we have. We have passed some 

rules over time with respect to some of the equipment we had seen 

develop over the years with hard padding, both in the shoulder 

area and the elbow area, and those potentially causing head injuries. So we have mandated padding of those areas areas of a player’s equipment. 

The helmet issue is a difficult issue, particularly in hockey, in 

terms of preventing concussion, and one of the things we are looking to work with our manufacturers on is research in terms of dealing with the rotational forces that can cause concussions, particularly in a sport like hockey, and whether a helmet can be designed 

to deal with those more effectively than it currently does. 

Mr. KINZINGER. Thank you, sir. 

Mr. Ogrean? 

Mr. OGREAN. I think Mr. Daly answered the question pretty well 

for our sport. There is a great deal where we rely on the National 

Hockey League to be the leader, and a lot of what they do is of benefit to us in a trickle-down fashion, but as I mentioned in my opening testimony, we do have a Safety and Protective Equipment Committee of 40-year standing. They do look at a variety of issues. The 

facemask, for example, is something that is mandatory—— 

Mr. KINZINGER. OK. 

Mr. OGREAN [continuing]. In youth hockey. It is not in the National Hockey League, though the shields for incoming players are 

now a standard. 

Mr. KINZINGER. I am going to have to cut you off just because 

of time. Mr. Miller? 

Ms. OGREAN. That will be fine. 

Mr. MILLER. Sure. Football helmets were designed to prevent 

against skull fractures, and they do a fabulous job of that. They 

were not designed to protect against concussion, and so that sort 

of technology or design, I know that the helmet manufacturers are 

working on it. We are not there yet, and the league is doing what 

it can to inspire that, especially with our partnership with GE and 

Under Armour, to get new ideas around that. And the other thing 

we do is we do regular helmet testing in concert with our friends 

at the Players Association, so that we can inform our players of 

which helmets are working best. 

Mr. KINZINGER. And, Mr. Hallenbeck, or, Ms. Scurry, you guys? 

Mr. HALLENBECK. Yes, trickle-down effect, again, is important 

there, and the only thing I would add is we are working now closely with the Sport and Fitness Industry Association and their new 

67 

Football Council, so we are getting insight from them, and working 

together on how we can improve things. 

Mr. KINZINGER. Thanks. And, Ms. Scurry? 

Ms. SCURRY. As you know, we don’t wear equipment in our—— 

Mr. KINZINGER. Right. 

Ms. SCURRY [continuing]. Sport, but I do want to commend your 

State for their Illinois Youth Soccer Association is taking a real 

lead in concussion awareness. I actually just did an event in Chicago just last weekend—— 

Mr. KINZINGER. OK. 

Ms. SCURRY [continuing]. For the association, and talking about 

concussions. And so your organization is doing a great job. 

But in terms of equipment for my sport, we don’t really have 

anything right now that is widely used, but hopefully in the future 

there could be something to help. 

Mr. KINZINGER. Great. Thank you. Mr. Chairman, I will yield 

back. 

Mr. TERRY. Gentleman from West Virginia is recognized for your 

5 minutes. 

Mr. MCKINLEY. Thank you, Mr. Chairman. I had to slip out for 

another meeting, so maybe some of these questions have been 

asked, but if you could help me out on this a little bit, one is: Is 

there anything that we can learn from the Defense Department 

with concussion injuries that we are hearing from when we talk to 

our troops that come back? I am just wondering if there is some 

way that we are all talking to each other? If you could help out on 

that. 

Mr. Miller? 

Mr. MILLER. Yes, I am happy to take that question. We are very 

proud of our relationship that we have fostered over the last couple 

of years with the U.S. Army and specific memorandum of understanding that went back a couple of years that covers a variety of 

different things. 

We have gotten current and retired players together with returning active service members to talk about cultural issues. What is 

it about football or what is it about the military that makes it very 

difficult for somebody to remove themselves from play, or, certainly 

in the case of the military, from a battle. We found a great deal 

of reticence on behalf of both populations, sort of a shared reticence 

to remove themselves from their comrades or teammates. And it instills a question as to how you get somebody to talk about, to tell 

their teammate or to tell their colleague, hey, you don’t look right, 

you should get off the field. And so we have learned a lot from that. 

And let me just add briefly as well, we meet regularly with the 

Army to talk about the research that they are doing from a scientific perspective. We share our agenda, we share the ideas that 

we have, and they do with us as well, and it has proven to be a 

very cooperative and beneficial relationship thus far. 

Mr. MCKINLEY. OK. Anyone else want to add to that, about our 

military? 

The second question has to do with, States have Workers’ Compensation programs to deal with the various disorders and injuries. 

Black lung in my State, it is treated in a way that people don’t 

have to take legal action to get help through the Workers’ Comp 

68 

program. Is that something that would be of benefit here in this 

program for injuries? A friend of mine has spent quite a few years 

in litigation with the NFL over this matter and just thinks it is 

such a cumbersome—and we also have an East Coast Hockey 

League team in our city, and we see so many injuries, and we hear 

from some of the players and coaches about that injury. Is there 

a time that we should have a Workers’ Comp program for brain injuries? Should that be included in something? 

Ms. SCURRY. If I—— 

Mr. MCKINLEY. If they are not required to file litigation to get 

help. 

Ms. SCURRY. If I may. My case actually is a Workers’ Comp case. 

I have gone through Workers’ Comp to get the different doctors, to 

see different techniques that will help me, and that is part of my 

situation and part of the reason why it has taken so long because 

every time something is suggested or recommended, I have to go 

back to the insurance company to get permission to do it, and 

sometimes it takes a hearing to get everything moved forward. So 

maybe streamlining that somehow would be of great help. 

And also in your previous question you talked about how can we 

help the military service people who have TBIs. For me, one of the 

best things I think would help is more of the psychological side and 

testing depression and anxiety and panic attacks to make sure that 

each person who comes back from the military who has a TBI gets 

help in that area, the emotional side of it, not just the physical. 

That would be very helpful, I think. 

Mr. MCKINLEY. OK, thank you. Any other thoughts? 

Mr. DALY. Well, Workers’ Compensation laws are really different 

jurisdiction by jurisdiction, including for us in Canada where professional athletes are specifically excluded in most Workers’ Compensation law, but it is certainly a mechanism that an increasing 

number of our former athletes are using in cases where they have 

debilitating injuries from their playing careers. 

Mr. MCKINLEY. So what was your recommendation then? You 

are saying yes? 

Mr. DALY. Well, again, I—— 

Mr. MCKINLEY [continuing]. We should be pursuing looking at 

that, or—— 

Mr. DALY [continuing]. I guess what I would say is, I think it is 

generally available to our former athletes currently, the Workers’ 

Compensation protection. 

Mr. MCKINLEY. I guess maybe that some of what we are hearing 

is different from that, that is why I want to raise it, but thank you 

for your comments about that. 

I yield back the balance of my time. 

Mr. TERRY. Gentleman yields back. Now Mr. Bilirakis from Florida, you are recognized for 5 minutes. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it very 

much. Thank you very much for holding this very important hearing, and I wanted to specifically thank Ms. Scurry for really speaking out. I really appreciate it. It makes so much of a difference, and 

thanks for your sacrifices. You are going to make a real difference 

in kids’ lives. 

69 

I also want to get back to the protective gear, the helmets, what 

have you. And how does the youth, and we can ask all of you, how 

does the youth helmet, the protective gear, compare as far as safety, quality, to the NFL and NHL? Can you give me an opinion on 

that? 

Mr. HALLENBECK. So I am certainly no expert on exactly how 

that compares, other than—I mean, my understanding is that there 

obviously is NOCSAE, the standard bearer, and they set the standards, and certainly all the helmets out there have to pass that 

standard, and I think the manufacturer, if they were sitting here, 

would say they go above and beyond that. How it compares to an 

NFL helmet, I think generally speaking, the youth helmet is lighter but the padding and so forth is appropriate. I don’t want to suggest I am defending them. I don’t know the exact details. I know 

it is sufficient based on standards and so forth. Many of the kids, 

though, I mean the players, youth players, I mean by 10 and 11 

and 12 years old, they are transitioning into what might be considered, you know, certainly high school or adult helmets, so they are 

getting the best available. 

And the other thing I would add is, certainly I am aware that 

the technology is improving in helmets and shoulder pads, and 

football equipment generally is definitely improving. 

Mr. BILIRAKIS. Mr. Miller? 

Mr. MILLER. Sure. We worked on a program with the Consumer 

Product Safety Commission, our Players Association, and some others recently that we would put money towards reconditioning older 

helmets for youth leagues. Certainly, the leagues that have, you 

know, budget constraints, as many do, probably don’t get around 

to updating their helmets or what they call reconditioning them 

frequently enough. And so we put a fair amount of money into that 

program in coordination with the CPSE. I know Scott, USA Football runs an equipment grant program as well. So, addressing 

those needs. We know that a new helmet is better than an old helmet. We know a reconditioned helmet is better than one that hasn’t 

been. Most important of all is that coaches learn how to fit the helmets. That is going to be the number one safety piece to the equation as it relates to kids. And so we are aware of these issues and 

we are trying to make a difference there as well. 

Mr. BILIRAKIS. So, in your opinion, the youth helmet or the high 

school helmet is not as safe as the NFL, but you do have a program 

to help. Is that correct? 

Mr. MILLER. Yes. I don’t know about the—— 

Mr. BILIRAKIS. The quality might not be as good. 

Mr. MILLER. I don’t know about the comparative safety of the 

helmets. 

Mr. BILIRAKIS. OK. 

Mr. MILLER. I suppose that is probably a question that—— 

Mr. BILIRAKIS. Can I talk to you about this—— 

Mr. MILLER. Of course. 

Mr. BILIRAKIS [continuing]. Particular program—— 

Mr. MILLER. No question. 

Mr. BILIRAKIS [continuing]. To help out, because I know for parents where the kids play high school football, and the parent will 

purchase a better quality helmet for their child, and, you know, I 

70 

am concerned about the kids that don’t have the, you know, the 

parents don’t have the money, you know, to purchase that, and it 

is so very important. So I would appreciate working—— 

Mr. MILLER. Happy to. 

Mr. BILIRAKIS [continuing]. With you on this. 

Mr. MILLER. Every kid deserves the proper equipment. 

Mr. BILIRAKIS. There is an existing grant program out there. I 

would like to hear about it. And then also, can I hear from the 

hockey as well—— 

Mr. OGREAN. Sure. 

Mr. BILIRAKIS [continuing]. NHL? 

Mr. OGREAN. At the youth level, I think the helmets are just as 

good as the National Hockey League, the only difference is size. 

They have to be certified by the Hockey Equipment Certification 

Council. There is a 3-year expiration date on every helmet. You 

can’t use a helmet that is more than 3 years old. 

Mr. BILIRAKIS. Very good. NHL wants to—— 

Mr. DALY. Yes. No, I would first echo Mr. Miller’s comments 

that, you know, helmets in our sport as well are principally designed to prevent skull fractures. They’re not principally designed 

to prevent concussions, and sometimes they can disperse force in 

a way that does prevent concussion but that is not their principle 

purpose. We also have regulations that we make available to our 

equipment managers and our players with respect to frequent replacing of helmets. So each player is essentially asked to replace 

his home helmet at least once a season, and his road team helmet 

at least two times a season, because we are worried about aging 

effects and degradation that accompanies travel requirements for 

our team. So frequent replacing of helmets is a priority for our 

league as well. 

Mr. BILIRAKIS. Are their coaches educated? I mean do they know 

which size fits the child? Have they been briefed on those particular issues, because that is so very important? Youth sports, 

hockey and football. 

Mr. OGREAN. They are. I agree with Mr. Miller that it is a big 

difference-maker, you know, in the helmet doing its job, but it is 

a pretty fundamental part of what a coach has to do to make sure 

the players on his team all have the proper equipment and are 

wearing it in the right way. 

Mr. BILIRAKIS. Very good, yes. Sir, would you—— 

Mr. HALLENBECK. And I would just add—— 

Mr. BILIRAKIS [continuing]. Like to comment? 

Mr. HALLENBECK. Yes. I would just add that it is a cornerstone 

of our Heads Up Football program—— 

Mr. BILIRAKIS. Very good. 

Mr. HALLENBECK [continuing]. Equipment fitting, because, frankly, at the youth and high school level, we have found they don’t 

know how to properly fit equipment, so it is a very important element within the program. 

Mr. BILIRAKIS. Thank you very much for including that. As far 

as, you know, the youth, of course, the NFL Hockey stars, what 

have you, baseball, basketball, they are looked up to by our children, as you know. Do you all have programs where you can 

speak—that speak, you know, maybe go to the schools, football 

71 

players, what have you, professional football players, go to the 

schools and speak on these particular issues? 

Mr. MILLER. Yes, our active players are, by and large, terrific at 

this topic. One of the elements that we included or offered up to 

USA Football as part of their Heads Up Football program was actually what we call an ambassador. So for leagues that were early 

adopters of the program, they would get visits and consultation 

with a retired NFL player. 

We are trying to encourage our clubs, with great success by the 

way, they have really done a terrific job of embracing in their communities the youth leagues and others, and so that they are around 

the facility more, that they interact with coaches, trainers, and certainly players, which obviously bring—the star quality of it brings 

attention to it, which was part of the motivation in the first place. 

But we have found retired players thrilled to participate, and really 

active and helpful to the end that you suggest. 

Mr. TERRY. All right, gentleman’s time has expired. 

Mr. BILIRAKIS. Thank you. 

Mr. TERRY. So if any of you want to answer that question, you 

will have to do it by writing. 

And brings me to the point that—you have a question, I am 

sorry. Recognize the gentlelady from Virgin Islands. 

Mrs. CHRISTENSEN. Thank you. And thank you, Mr. Chairman. 

Sorry I am late, I was at another hearing downstairs. 

Mr. Miller, I would like to ask you this question. Many tens of 

thousands of helmets are used every year that are more than 10 

years old. I understand that the NFL participated in a program initiated by the Consumer Product Safety Commission by donating 

money that would go towards new helmets for youth football players in low income communities, and I really want to commend the 

NFL for this initiative. 

Of course, it is going to cost a lot more money to get to the point 

where virtually all kids around the country who play football no 

longer wear old helmets that are likely degraded or obsolete. I am 

pleased to know of your donation to the CPSC initiative, because 

it strikes me as an acknowledgement that wearing an old helmet 

when playing football is not advisable. A statement from the NFL 

that would be very influential. We have also heard that reconditioning those under 10 years old is important to ensure the proper 

foam density, and that other degraded parts of the helmet are replaced. 

So I wanted to ask you the following questions for a yes-or-no answer. I guess that is why I am sitting in Chairman Dingell’s seat. 

We realize that many issues are subject to negotiations, but can 

the NFL commit to supporting prohibiting helmets on the field that 

are over 10 years old? 

Mr. MILLER. In the youth space? You are talking specifically 

about youth football, prohibiting helmets that are—— 

Mrs. CHRISTENSEN. Yes. 

Mr. MILLER [continuing]. Older than 10 years there? I, you know, 

I plead not enough familiarity with the issue. I know that there are 

a couple of States who have taken that step, and we would be 

happy to work with you to pursue it. The prime place that, as you 

72 

mentioned, that we work within in promoting new or refurbished—— 

Mrs. CHRISTENSEN. Well—— 

Mr. MILLER [continuing]. Helmets is with the CPSC or through 

USA Football, who has a grant program as well, but—— 

Mrs. CHRISTENSEN. So the first question is committing to supporting prohibiting helmets on the field that are over 10 years old. 

Could you commit to the supporting of policy position that helmets 

more than 10 years old present an unacceptable safety risk? That 

is the position that is taken by most of the helmet industry. 

Mr. MILLER. If that is the position of the helmet industry, I 

would see no reason why we would have a concern with that. That 

sounds appropriate. 

Mrs. CHRISTENSEN. Riddell and Adams strongly recommend that 

their helmets should be discarded after 10 years. Can the NFL 

commit to supporting a policy position recommending that helmets 

be discarded after 10 years? 

Mr. MILLER. We would certainly support the helmet companies 

and how they advise people to use their products. 

Mrs. CHRISTENSEN. We have also heard stories of players using 

beat-up lucky college helmets, or adjusting their helmets by perhaps removing some padding in the helmets for comfort. Will the 

NFL commit to support a policy position that all players should 

wear helmets that are reconditioned properly? 

Mr. MILLER. Well, all of our players have choices in which helmets they use, as long as they pass the NOCSAE, the certification 

by these standards. And so that is something that is a point of discussion with our Players Association, and players have to use helmets that pass the standard. So I—— 

Mrs. CHRISTENSEN. And that means—— 

Mr. MILLER [continuing]. We are happy to support that. 

Mrs. CHRISTENSEN [continuing]. That they were reconditioned 

properly, and they had the appropriate padding? 

Mr. MILLER. Sure. The NFL players’ helmets are reconditioned 

regularly, is my understanding, and our equipment managers work 

with the players to make sure that their helmets are in good working order. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. 

Mr. TERRY. Thank you very much. 

[Recess.] 

Mr. TERRY. All right, why don’t we have our witnesses take their 

respective places? OK, if we could have everybody take their seats. 

And as you are settling in, this is, pun intended, the more heady 

part of our hearing today where we are dealing with neuroscience 

and medical research and physics—well, physics when Dr. Gay arrives. 

So panel two, I will introduce you from Mr. Cleland on down. Mr. 

Cleland is the Assistant Director, Division of Advertising Practices 

at the Federal Trade Commission. We have Ian Heaton, Student 

Ambassador for the National Council on Youth Sports Safety. And 

if I might editorialize, I think Jan did a great job of juxtaposing 

a face of TBI and concussions on each panel. And Ian, as a high 

school lacrosse player, is that face for the more scientific-based 

panel. So thank you, Ian, for taking your day away from school. I 

73 

know how tough it is to be pulled out of school and come testify 

before Congress. Just like a normal high school student. Then Dr. 

Robert Graham, Chair, Committee on Sports-Related Concussion in 

Youth at the Institute of Medicine. Dennis Molfese, Ph.D., Director, 

Center for Brain, Biology, and Behavior at the famed University of 

Nebraska. Thank you, Doctor. Then Dr. James Johnston, Assistant 

Professor, Department of Neurosurgery at the University of Alabama Birmingham. Star of screen, Dr. Tim Gay, Ph.D., Professor 

Atomic, Molecular and Optical Physics, University of Nebraska. 

Gerard Gioia, Ph.D., Division of Chief Neuropsychology, Children’s 

Medical Hospital. And not quite up to the level of University of Nebraska, we have the Harvard Medical School. That is just humor. 

Professor of—— 

VOICE. Ha ha. 

Mr. TERRY. Yes. Professor of Psychiatry and Radiology at 

Brigham and Women’s Hospital, Harvard Medical School. Thank 

you for being here for a very impressive and esteemed panel of scientists and experts. 

And, Mr. Cleland, we will start. You are now recognized for your 

5 minutes. 

STATEMENTS OF RICHARD CLELAND, ASSISTANT DIRECTOR, 

DIVISION OF ADVERTISING PRACTICES, BUREAU OF CONSUMER PROTECTION, FEDERAL TRADE COMMISSION; IAN 

HEATON, STUDENT AMBASSADOR, NATIONAL COUNCIL ON 

YOUTH SPORTS SAFETY; ROBERT GRAHAM, DIRECTOR, 

ALIGNING FORCES FOR QUALITY, NATIONAL PROGRAM OFFICE, GEORGE WASHINGTON UNIVERSITY; DENNIS L. 

MOLFESE, DIRECTOR, BIG 10-CIC-IVY LEAGUE TRAUMATIC 

BRAIN INJURY RESEARCH COLLABORATION; JAMES JOHNSTON, ASSISTANT PROFESSOR, DEPARTMENT OF NEUROSURGERY, UNIVERSITY OF ALABAMA-BIRMINGHAM; TIMOTHY J. GAY, PROFESSOR, DEPARTMENT OF PHYSICS AND 

ASTRONOMY, UNIVERSITY OF NEBRASKA-LINCOLN; GERARD 

A. GIOIA, CHIEF, DIVISION OF PEDIATRIC 

NEUROPSYCHOLOGY, CHILDREN’S NATIONAL HEALTH SYSTEM; AND MARTHA E. SHENTON, PROFESSOR OF PSYCHIATRY AND RADIOLOGY, BRIGHAM AND WOMEN’S HOSPITAL, 

HARVARD MEDICAL SCHOOL 

STATEMENT OF RICHARD CLELAND 

Mr. CLELAND. I am Richard Cleland. I am assistant director for 

the Division of Advertising Practices at the Federal Trade Commission’s Bureau of Consumer Protection. I am pleased to have this 

opportunity to provide information about the actions we have taken 

over the past few years with respect to concussion protection 

claims; claims that implicate serious health concerns, especially 

those potentially affecting children and young adults are always a 

high priority at the Commission. 

The Commission strives to protect consumers using a variety of 

means. First and foremost, the Agency enforces Section 5 of the 

Federal Trade Commission Act, which prohibits deceptive and unfair acts or practices. In interpreting Section 5, the Commission 

has determined that a representation, omission or practice is deceptive if it is likely to mislead a consumer acting reasonably under 

74 

the circumstances, and it is material that it is likely to affect the 

consumer’s conduct or choice decision about a particular product at 

issue. 

The Commission does not test products for safety and and efficacy; it does, however, require that an advertiser have a reasonable 

basis for objective claims conveyed in an ad. The Commission examines specific facts of the case to determine the type of evidence 

that will be sufficient to support a claim. However, when the 

claims involve health and safety, the advertiser generally must 

have competent and reliable scientific evidence substantiating that 

claim. 

As awareness of the dangers of concussion has grown, sporting 

goods manufacturers have begun making concussion protection 

claims for an increasing array of products. These include football 

helmets and mouth guards, but also include other types of products. 

In August 2012, the Commission announced a settlement with 

the makers of Brain Pad mouth guards. The Commission’s complaint alleged that Brain Pad lacked a reasonable basis for its 

claims that the mouth guards reduced the risk of concussions, particularly those caused by lower jaw impacts, and falsely claimed 

that scientific evidence proved that the mouth guards did so. The 

final Order in that case prohibits Brain Pad from representing that 

any mouth guard or other equipment designed to protect the brain 

from injury will reduce the risk of concussions, unless the claim is 

true and substantiated by competent and reliable scientific evidence. In addition, the Commission sent out warning letters to 

nearly 20 other manufacturers of sports equipment, advising them 

of the Brain Pad settlement, and warning them that they might be 

making deceptive concussion claims about their products. 

The FDC has monitored these Web sites and is working with 

them as necessary to modify their claims on their sites, and in 

some cases, ensure that the necessary disclosures are clear and 

prominent. Commission staff continues to survey the marketplace 

for concussion reduction claims, and alert advertisers who are making potentially problematic claims of our concerns, and of the need 

for appropriate substantiation for such claims. 

Commission staff also investigated concussion reduction claims 

made by three major manufacturers of football helmets; Riddell 

Sports, Incorporated, Schutt Sport, Incorporated, and Xenith, LLC. 

In these matters, the staff determined to close the investigations 

without taking formal action, by which time all three companies 

had discontinued the potentially deceptive claims or had agreed to 

do so. Those cases are discussed in greater detail in the Commission’s written testimony. 

The Commission plans to continue monitoring the market for 

products making these claims, to ensure that advertisers do not 

mislead consumers about the product’s capabilities or the science 

underlying them. At the same time, we are mindful of the need to 

tread carefully so as to avoid inadvertently chilling research, or impeding the development of new technologies and products that 

truly provide concussion protection. 

The Commission appreciates the committee’s interest in this very 

important area, as well as the opportunity to discuss our Agency’ 

75 

effort to ensure that the information being provided to consumers, 

in particular, to the parents of youth athletes, is truthful and not 

misleading. 

Thank you. 

[The prepared statement of Mr. Cleland follows:] 

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Mr. TERRY. Thank you. Now, Ian, you are now recognized for 

your 5 minutes. 

STATEMENT OF IAN HEATON 

Mr. HEATON. Chairman Terry, Ranking Member Schakowsky, 

and members of the subcommittee, thank you for the opportunity 

to share my story today. 

My name is Ian Heaton, and I am here as a student ambassador 

for the National Council on Youth Sports Safety. I am also a senior 

at Bethesda Chevy Chase High School in Bethesda, Maryland. 

I was a sophomore playing in a high school off-season lacrosse 

game when I sustained a serious head injury that we later discovered was my third concussion. Until then, I did not appreciate 

what a great life I was living. I got good grades in challenging 

classes, played high school lacrosse, was working on my second degree black belt in martial arts, had a job I loved teaching 

taekwondo, performed at my school’s jazz ensemble and combo, and 

had an active social life. It was over in a split second. 

My concussion left me with only 5 percent of normal cognitive activity, and I was almost immobilized. 

I have spent 2 1⁄2 years recovering, and, at times, have even wondered if I would ever get that life back. It has been a long, slow 

process. 

At first, all I wanted to do is sleep. Noise, light, and even moving 

my eyes caused headaches and nausea. I was enrolled in the Children’s Hospital SCORE Program that Dr. Gioia will describe later, 

where I received ongoing cognitive evaluation and treatment for 

symptoms. 

After missing school for 2 weeks, I tried to go back but was unable to function. The frustration of trying to focus on lectures, moving through the pandemonium of the halls, and the constant sensory bombardment made a normal school day impossible. However, 

through my school, I eventually enrolled in a home teaching program, and with the help of my tutors and family, was able to complete my semester coursework at my own pace. I finally returned 

to school in December but was still far from recovered. 

I have spent the 2 1⁄2 years since my concussion slowly regaining 

organizational skills, the ability to learn and retain information, 

and, most important, my personality. During this time, my friends 

and family learned to recognize the signs that meant I needed to 

shut down from any kind of mental or physical activity for a day 

or two. These relapses were particularly tough and discouraging, 

and meant that I had to drop a class and miss a band trip to Chicago, among other things. The worst was when I had a crash and 

could not go to my first concert, the Red Hot Chili Peppers. The 

friend I gave my ticket to really owes me. 

The spring after my injury, I was medically cleared to return to 

sports, but made the hard decision that I would not play lacrosse 

or other intensive sports again. I know that a lot of people recover 

and return to play, but the possibility of another concussion means 

I could lose everything again, just like that, and not come back the 

next time. 

I now look at my recovery as something that has made me 

stronger, but I know that I am one of the very lucky ones who had 

85 

the resources and medical attention I needed, and a school system 

that is aware of concussion issues and provided an unusually high 

level of support. 

It is not over yet. My recovery continues, but my outlook is positive and I am excited about the future as I prepare for college. I 

am thinking about becoming a high school math or science teacher. 

I now have a hard question. What can be done to create a safer 

sports environment, and to ensure that when injuries do occur, the 

support for a full recovery is available? We can’t just do away with 

youth sports. I have played baseball, travel soccer, and league and 

high school lacrosse, and being on those teams not only gave me 

a healthy outlook, it taught me important lessons. 

Sports are one of the best parts of growing up and becoming a 

strong adult. They teach us that if we work hard, we will become 

skilled and proud of our accomplishments. They teach us how to be 

part of a team, to have pride and success, and learn the lessons of 

defeat. They teach us that sometimes we have to quit thinking of 

ourselves and think of the good of the team. For these and many 

other reasons, I hope that steps can be taken so that future young 

athletes have these opportunities. 

There are two important things I think would make a big difference. The first is to change the cultures of hitting hard to take 

out a good opponent, rather than playing to win through skill, and 

brushing off injuries to get back into the game. While better equipment may decrease injuries, it is coaches, parents and players who 

have to back away from the need to win at all costs, or fear the 

losing status on the team when out for an injury, to be willing to 

recover fully before returning to play. It will take a while, but if 

youth and professional sports are to survive, these attitudes must 

be embraced. 

Second, when injuries do occur, we must have a way for qualified 

personnel to quickly assess injuries on the field, have players get 

immediate attention, and then support recovery through schools 

and medical institutions. These are the things that were done for 

me, and are the reason I have been able to return to normal. 

As a student ambassador for the NCYSS, the message I hope to 

give young athletes is this. You think you are invulnerable. You 

take risks and brush off injuries because you think you will recover 

quickly from anything happens. You won’t. Don’t be a hero, especially when it comes to your head. It is the only brain you will 

have, and your personality is who you are. It is not worth a couple 

of seasons of glory to lose the opportunity of a lifetime. 

Thank you. 

[The prepared statement of Mr. Heaton follows:] 

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Mr. TERRY. Very good. Dr. Graham, you are recognized for 5 minutes. 

STATEMENT OF ROBERT GRAHAM 

Mr. GRAHAM. Thank you very much, Chairman Terry, Ranking 

Member Schakowsky. 

My name is Bob Graham. I served as the chair of the Institute 

of Medicine, Sports-Related Concussions in Youth Study. As you 

have my testimony before you, and I think copies of the study 

itself, I will just try to take these minutes just to give you a summary. 

The Institute of Medicine is part of the National Academy of 

Sciences, which is chartered by the Congress to provide advice to 

the Congress and to the Executive on various scientific issues. We 

were specifically empaneled to look at the evidence about the 

causes and consequences of concussion in youth and military, the 

state of concussion diagnosis and management, the role of protective equipment, and sports regulation. 

We had 17 members on our committed. We worked in 2013. Dr. 

Molfese, who will follow me, was a member of that committee, and 

we came with just six recommendations. The first was that the 

CDC needed to establish a better mechanism for national surveillance to comprehensively capture the incidents of concussions. You 

have heard a number of figures this morning about the concussions 

in one sport or another. We know what the incidence is where they 

are measured. We do not know what the incidence is in sports 

where they are not measured, or where they are not more closely 

watched. We need to have that baseline to really know the degree 

to which we have a problem, and as we take corrective measures, 

the success rate that we are having in making an impact on decreasing the incidence of concussions. 

So, number one, we need better surveillance, we need better 

epidemeality. Number two, a couple of recommendations related to 

research. We need the NIH and the DOD to look more specifically 

at what metrics and markers are for concussions. How do you assess the severity of a concussion, how do you find diagnostically 

whether or not an individual has had a concussion. Right now, it 

is largely based upon observation, on self-report, but are there 

some physiologic markers that could be used to give us better documentation that a concussion has actually occurred, perhaps without 

the individual knowing it or without it being observed. Secondly, 

we need the NIH and DOD to look at more carefully and longitudinally at the short- and long-term consequences of concussions. 

We have heard testimony in this panel, the prior panel, individuals 

that have had one or more concussions, what are the long-term 

sequella of an individual or multiple concussions. That gives us 

some sense about not only, again, the epidemiology of the problem 

that we are dealing with, but what treatment and interventions 

may be, and what rehabilitation may be. 

Fourth recommendation was to the NCAA and the National Federal of State and High School Associations to look at age-appropriate techniques, and roles and playing standards. And again, 

your first panel talked a little bit about that, mostly at the professional level, but can you change the manner in which the sport is 

90 

1The report ‘‘Sports-Related Concussions in Youth: Improving the Science, Changing the Culture’’ and the accompanying slide presentation have been retained in committee records and also 

are available at http://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=101897. 

practices, and the rules of engagement in the sport that may decrease the risk of concussion. There was one example from the 

hockey area where they had changed the level where they allowed 

body checking, and felt that they saw a decrease in concussion. We 

think that that same sort of examination should take place at the 

college and the elementary and high school level to see whether or 

not that can have the same impact. 

The fifth recommendation had to do with a better study of what 

the role may be for protective equipment. And again, your first 

panel talked a lot about that. The committee had a number of 

questions about that. Our committee found that there was very little evidence that helmets protect against concussions. And there is 

a lot of data in that, and I think some of the other panelists will 

be talking about that. You may come away with an equivalence degree in physics this morning. It is a complicated issue, but there 

are a number of suggestions. You know, we certainly did not recommend you don’t use helmets. They do protect against bone injury 

and soft tissue injury, but the suggestion that a helmet itself may 

decrease the incidence of concussion, the evidence does not appear 

to be there to us, and we think that the NIH and DOD, again, have 

a role in looking more specifically at what we may be able to do 

related to the biomechanical determinates and protection against 

concussions. 

And then our final recommendation had to do with the topic 

which has come up frequently, and that is changing the culture 

and the way concussions are viewed. This is a significant injury. 

Athletes need to be encouraged to report, to take themselves out 

of the game. Coaches and parents need to be encouraged to say, for 

your own protection, you need to be removed and give yourself a 

chance for recovery. 

Thank you very much. 

[The prepared statement of Mr. Graham follows:] 1

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

STATEMENT OF DENNIS L. MOLFESE 

Mr. MOLFESE. Thank you, Chairman Terry, Ranking Member 

Schakowsky, and members of the subcommittee for this opportunity. 

If we could have the slides. Go to the next slide. Yes. So I think 

the earlier group talked about a number of—if you can go ahead 

and put that on Power Point—a number of sports where the rate 

of concussion is particularly high. There are, of course, differences 

in rates for men and women, and Dr. Gay will talk about some of 

that in terms of weaknesses of women’s necks relative to men’s 

necks and how that puts them perhaps at more risk for concussion. 

Next slide. Concussion accounts for, in the United States, roughly about 75 percent of traumatic brain injuries. It is a brain injury. 

There is damage to the brain. There is the discussion about whether it is permanent or temporary. In the military, the rate is 77 percent. So it turns out that youth sports are a good model for also 

looking at concussion in terms of the military. And, in fact, most 

of the military concussions occur in situations most like they do 

with the rest of America. Some certainly occur in theater, but majority occur outside of theater in accidents like we all are sort of 

prone to experience. 

Next slide. If we look at brain injuries overall, there are estimates—these are all estimates, of course, and they vary across the 

literature, but we are looking at somewhere probably in the neighborhood of about 4 million traumatic brain injuries per year in the 

United States. Severing part of that is that our birth rate in the 

United States is also roughly about 4 million. This does not count 

other ways that children are exposed to head injuries. Perhaps a 

disciplining, irate parent who slaps a child, that creates rotational 

movement that can, in fact, produce a concussion. Those, one would 

suspect, are largely unreported. 

Recovery generally is fairly quick, usually within anywhere from 

a few hours to a few days. Some will persist to 2 weeks, even perhaps out to 6 weeks, but roughly about 20 percent seem to persist 

beyond that time. 

Next slide, please. This is a slide just on some data that we have 

under review, but it will give you sort of a sense. These are data 

recorded using brain electrical activity. So basically, you have a net 

of 256 electrodes that fits on the head in about 10 seconds or so. 

And we present a series, in this case, a series of numbers. One 

number at a time. All the college athletes had to do was simply say 

whether the number they currently see matches or does not match 

a number that occurred two positions earlier. And on the left side, 

those orbits, those circles you see, the colored circles on the left for 

match and non-match, those are imagines of the brain electrical activity on the scalp recorded from those electrodes, between 200 and 

400 milliseconds. So 2 tenths to 4 tenths of a second after the number appears. So the schematic on the right shows you the head position. So it is a very rapid brain response. For those athletes who 

have no history of concussion, we see a very clear difference in the 

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low and green in the top left orb, and in the bottom we see red and 

various shades of blue from the front of the head to the back of the 

head. On the right though, these are individuals who have a concussion history of 1 to 2 years earlier, not current, and yet at 200 

to 400 milliseconds, their brains cannot discriminate whether those 

two numbers are the same or different. They ultimately get these 

tasks correct, but it takes them roughly 200 milliseconds longer. 

That is 20 synapses. So the processing speed is slow. And after 2 

years, one might suspect that is a permanent change. 

The next slide, I think that—yes, so in terms of critical scientific 

gaps, some of these we do what Dr. Graham talked about, you 

know, how does concussion affect the brain in the short and long 

term. We really don’t have much information about that. What is 

the dose requirement, Dr. Graham talked about that, to produce a 

concussion, post-concussion syndrome, CTE, how can we reliably, 

objectively detect when the brain is injured, and when, importantly, it is fully recovered. We have no ways to do that. Lots of 

individual differences from one person to the next. We think there 

are genetic factors involved, but there could also be a concussion 

history that a person may not really think they have. How many 

of us have bumped our head getting in and out of a car. So we have 

a quick rotational movement, and that could produce perhaps a 

concussion. And then how does the brain recover from TBI. And 

then, finally, how we improve and accelerate recovery. We really 

have no scientific basis for any of our interventions. 

Thank you. 

[The prepared statement of Mr. Molfese follows:] 

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Mr. TERRY. Thank you. Dr. Johnston, you are now recognized for 

5 minutes. 

STATEMENT OF JAMES JOHNSTON 

Mr. JOHNSTON. Hi, Chairman Terry, Ranking Member 

Schakowsky, and members of the committee. Thank you for inviting me to testify before you today, alongside this illustrious panel 

about our experience in Alabama following the passage of concussion legislation, as well as the work we are currently doing at the 

University of Alabama Birmingham to improve sports safety. 

As in the State of Nebraska, youth sports and youth football are 

an extremely important part of our culture, and as a result, we 

take the safety of our children very seriously as well. 

As well known to the committee, the problem of concussion has 

gained prominence over the past decade thanks to important research and advocacy work done by scientists, physicians, and public health professionals at many centers across the United States, 

and through the work of public officials highlighting this research. 

Of significant concern, recent studies have identified potential longterm health consequences including depression, chronic traumatic 

encephalopathy and other neurodegenerative diseases associated 

with repeated impacts. 

While college and professional football gets the most media attention, it is important to keep in mind that greater than 70 percent of all football players in the U.S. are under 14 years of age. 

Any effort directed at improving safety in football and other impact 

sports will need to address these youth athletes. 

Parallel to enacting of Alabama’s concussion law in 2011, as in 

many States, the Alabama State Concussion Taskforce, Children’s 

of Alabama, and Think First Alabama, initiated a statewide concussion education and awareness program, and it worked. In that 

first year, we observed a 500 percent increase in referral of youth 

athletes referred to the Concussion Clinic at Children’s of Alabama, 

a trend that has held steady since that time with about 350 youth 

athletes seen every year. 

To optimize care of this rapidly increasing patient population, we 

developed a multidisciplinary protocol, it is in my Appendix 1, following the Zurich Consensus Guidelines, athletes were evaluated 

by physicians with expertise in concussion, kept out of sports or 

school until symptom-free, referred for neuropsychological testing 

when appropriate, and supervised in a gradually return to play 

and/or return to think program. A formal study performed in 2012 

demonstrated that establishing this program resulted in significantly better concussion care and decreased institutional resource 

utilization. 

Even though these efforts have certainly resulted in improved 

recognition and treatment of concussion in Alabama and in other 

States, we believe that much remains to be done in order to prevent sports-related brain injury in the first place. Given the difficulty of delineating a specific concussion threshold, as has been 

said previously, using existing helmet accelerometer technology 

and other subjective ways of evaluating athletes, researchers have 

begun to widen their focus from concussion to correlating cumulative impact exposure over time, with changes in advanced MRI 

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imaging techniques and neuropsychological changes, even in the 

absence of clinically diagnosed concussion. Animal models of subconcussive impacts have also demonstrated problems with complex 

spatial learning, cognitive impairment, and, as is seen also in football players, compared with single impact controls and those who 

have not had these injuries. 

Though definitive conclusions about threshold for impact frequency hit counts cannot be drawn from these early studies, it has 

become clear that subconcussive impacts, that is, those impacts 

that don’t result in concussion, also play a role in cumulative brain 

injury over time and need to be studied. 

Recent studies of youth players by researchers at Wake Forest 

suggest that a significant portion of young players’ head impact actually takes place during practices, and the largest impacts happen 

to take place during those practices, a lot of time doing outdated 

drills, like Oklahoma Drill or Bull in The Ring, that are supervised 

by well-meaning but untrained coaches. Emulating top level collegiate programs, which don’t do these practices and these drills, 

teams like the University of Alabama, Ivy League and others, the 

Alabama High School Athletic Association recently published nonbinding guidelines to limit full contact hitting practices to twice per 

week. I believe this type of intervention is complimentary to the 

stuff that USA Football is talking about, about techniques, not just 

the techniques of hitting but also the number of hitting practices 

per week, as well as what drills are going to be done during practice. Pop Warner has instituted similar guidelines to this, but 

again, that is a small section. Limiting the frequency of hitting at 

practices as well as the type of drills would have a large effect on 

safety, significantly decreasing the cumulative impact exposure for 

every youth football player in America. 

It has also become clear that football helmet standards currently 

defined by the National Operating Committee for Standards in 

Athletic Equipment must be updated to reflect or improve understanding of the etiologies of concussion. It is clear that both linear 

impact and rotational acceleration play a role in concussion 

pathophysiology, and only linear impact is studied by the NOCSAE 

system, which was from a skull fracture tolerance model developed 

in the 1960’s. 

We believe that having a more complete picture of the impacts 

that are seen in the football field are necessary in order to come 

up with meaningful standards. In collaboration with the University 

of Alabama Football Program, engineers at UAB, led by Dean Sicking, previously of the University of Nebraska, and the developer of 

the safer barrier for NASCAR and IRL have recently developed a 

robust video analysis system to analyze impacts, and then recreate 

them in a purpose-built lab. 

In conclusion, the passage of concussion awareness legislation, 

community education, and recent advances in our understanding of 

head impact exposure in youth athletes have all improved the overall safety of impact sports, and that we are recognizing concussions 

more frequently, however, much work remains, specifically in concussion education, and drafting of policies to limit head impact exposure for youth athletes in contact sports. As part of this push to 

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opment of new helmet standards is also crucial for the development 

of safer helmets. 

Mr. Chairman, thank you for the opportunity to testify. 

[The prepared statement of Mr. Johnston follows:] 

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Mr. TERRY. Thank you. Dr. Gay, you are now recognized for 5 

minutes. 

STATEMENT OF TIMOTHY J. GAY 

Mr. GAY. Thank you, Chairman Terry. I would like to thank the 

subcommittee for inviting me to testify today. 

I am speaking to you as a football fan who happens to be a physicist. My main professional interest in the game is the understanding of how protective equipment works and how it can be improved. 

Today I wish to consider several aspects of football that are problematic as far as concussions go, and how we might move forward 

to make the game safer. 

American football is an inherently violent sport. That is one of 

the reasons we love it. The forces encountered in football can be 

huge. Consider a big hit between a running back and a linebacker 

at full speed. We can show, using Newton’s Second Law, that the 

force each player exerts on the other exceeds 3⁄4 of a ton. This is 

why football is called a contact sport. 

Two players who collide at full speed, helmet to helmet, are experiencing the same force to their heads that one of them would feel 

if he had a 16-pound bowling ball dropped on his helmet from a 

height of 8 feet. 

Medical knowledge of concussions is in its infancy, but we know 

one thing for sure: Forces to the head and neck cause concussions, 

and we have just heard how big these forces can be. Here is another problem: They are getting bigger. 

Since 1920, the average weight of pro linemen has increased almost 60 percent, to just over 300 pounds. At the same time, these 

players have gotten about 10 percent faster. Combining the factors 

of speed and mass to calculate kinetic energy, the energy available 

to cause injury, we find that the amount of energy dumped into the 

pit at the line of scrimmage on any given play has almost doubled 

since 1920. In exact opposition to this trend is the fact that players 

are shedding their protective gear. Thigh and kneepads that used 

to be centimeters thick, now bear a remarkable resemblance to teacup doilies. Horse collars, popular with linemen of my generation, 

have gone the way of the flying wedge. Modern football helmets are 

technological marvels, but players choose them not for their collision cushioning ability, but for how cool they look. 

Another problem is the poor state of our medical knowledge. 

While I am not competent to explain these issues, I think it is safe 

to say that a room full of head trauma physicians will not agree 

on the details of what concussions are, or what causes them. This 

means that the diagnosis and treatment of concussions has a long 

way to go. As our understanding of these issues improves, we may 

find that injury rates due to the increasing energy of the game and 

the wholesale shedding of equipment have increased faster than we 

thought. 

Finally, football is big business, especially at the college and professional levels. When monetary forces manifest themselves as they 

do in, for example, bounty programs and illegal doping to improve 

performance, the game becomes more dangerous. 

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What are the solutions? We need better equipment, but this can 

get tricky. For example, it is apparent that adding more energy absorbing foam to the outside of a helmet will lower the force delivered to a player’s skull. This has been tried in the past. The problem is that the added padding increased the helmet diameter, as 

well as its coefficient of friction, meaning that the opposing player 

can exert a lot more torque on your head. Nonetheless, several 

companies today are proposing the same basic padding idea for 

youth football, for whose players the risk of collisions to the head 

is almost certainly greater. The use of the Star System for rating 

helmets, and the Hit System for monitoring collisions to a player’s 

head, represent important first steps toward improving football 

safety for a variety of reasons that disregard players’ safety, they 

are largely ignored. 

Our understanding of the physiological and epidemiological 

issues related to concussions must be improved. There is now an 

understanding in the NFL and at the college level that significant 

research in this area is needed. Several of the members of this 

panel, including my colleague from Nebraska, Dr. Molfese, are 

leading cutting-edge efforts in this area. 

Finally, some incremental rule changes and more stringent enforcement of existing rules are needed. In my opinion, some of the 

new rules regarding targeting, peel-back blocking, and definition of 

a defenseless opponent, are making players more hesitant on the 

field. These rules may, thus, actually, increase the risk of injury. 

Rule changes should be studied and possibly reversed. 

It is my belief that a return to the level of padding worn in the 

1970s would make the game significantly safer. More thorough 

doping rules should be developed and actually enforced. The NFL 

season should be reduced to 14 games, and the college season returned to 11. Finally, more stringent requirements regarding when 

a player with a concussion can return to the game need to be implemented. 

These are my thoughts for your consideration. Thank you for 

your attention and your valuable time. 

[The prepared statement of Mr. Gay follows:] 

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Mr. TERRY. Thank you for your valuable time. 

And, Dr. Gioia, I appreciate you being here. You are recognized 

for 5 minutes. 

STATEMENT OF GERARD A. GIOIA 

Mr. GIOIA. Yes. Thank you, Chairman Terry, Ranking Member 

Schakowsky, and members of the subcommittee. I appreciate the 

opportunity to speak on behalf of the safety of our children in this 

country. 

So I am a pediatric neuropsychologist at Children’s National 

Health System here in Washington, DC, and the director of the 

SCORE Concussion Program. I am a clinician, a researcher, and a 

public health educator. Today I would like to take my time to focus 

my comments on the importance of public health education for 

youth concussion, using my expertise as a clinician and a researcher, and I have worked for the last decade with the CDC on 

their Heads-up Concussion Program materials. 

We all know, and I think Ian said it just perfectly, that sports 

and recreation provide important developmental opportunities to 

enrich the lives of our youth. They teach life lessons. But we have 

to balance those incredible benefits of sports participation with 

careful attention to safety issues, and science must drive our action-oriented approach. 

Concussions are serious injuries to the brain that threaten the 

development of our youth. In an attempt to protect our youth, we 

now have laws in all 50 States and the District of Columbia, all 

with the good intent of protecting our student athletes through 

rules for educating coaches and parents, and removing suspected 

concussions, and not allowing them to return until properly 

cleared. All States include the high school at this level, but only 15 

out of those 51 include youth sports. So less than 1⁄3 are looking 

at the majority of athletes. 

In preparing for this testimony, I was posed with an important 

question and challenge within youth sports. With concussion 

awareness now at an all-time high, are youth sports teams and organizations, and parents, more aware but still not sure what to do 

about it. And the simple answer to that question, with my experience, is yes. Many coaches and parents are not equipped to know 

what to do with a suspected concussion. Mechanisms to teach active recognition and response to every coach and parent are inconsistent and limited in scope. The health and safety of youth athletes is largely in the hands of coaches and parents at the youth 

level. They need medically guided training and early identification 

of concussion and protection. Coaches and parents must receive 

training and action-oriented concussion recognition and response. 

Awareness isn’t enough, and they have to be prepared properly. 

We know that, as you have heard, repeated concussions present 

the greatest challenge to our youth. So our greatest challenge is 

really the universal consistent and effective implementation of 

these 51 laws so that we can prepare those coaches and parents to 

know what to do, and have the tools with which to do it. 

At Children’s National Health System, over the past 10 years, 

our SCORE Program has delivered hundreds upon hundreds of action-oriented parent and coach concussion education and training 

142 

program, using the Heads-up materials from the CDC. We have 

learned much about the community needs and how to deliver the 

message. So we deliver scenario-based training where we present 

to coaches and parents an actual situation, and what they must do 

to recognize and respond. This is all very, very important as we put 

these responsible adults in place. 

You have heard about some important other kinds of activities 

and good examples of head-safe action, head-smart action, such as 

USA Football’s Heads-up Tackling Program, where coaches are 

educated in concussion recognition and response, but also taught 

techniques that we believe can improve taking the head out of the 

game, but we have to go further in all youth sports. We do not 

have a coordinated universal strategy at this point for action-oriented, solution-driven methods to recognize and respond to these 

injuries. We have the tools, we have many of the programs, but we 

do not at this point have the delivery mechanism to do that. So we 

have to build also on active partnerships between youth sports organizations and medical care systems. Concussions are complicated. They are not simple. We are not asking parents and 

coaches to be clinicians and to go out and diagnose. We have willing teammates, as you have heard, through USA Football, U.S. Lacrosse, USA Hockey, USA Rugby and other organizations, but we 

need to build those partnerships, we need the help of the professional sports leagues, as you hearing from the NHL and the NFL 

and the sports manufacturing world, to team with us. We also need 

a quarterback ultimately to make this happen. We have to leverage 

the efforts of other organizations like the National Council on 

Youth Sports Safety, the Youth Sports Safety Alliance, The Sarah 

Jane Brain Foundation’s PABI Plan, all of this is important for us 

to do. So we need, obviously, funding to do that to move forward. 

Can we move from awareness to action? Yes, we can. Concussions are serious injuries that threaten our youth, but we do not 

need to be scared away from that, we do not need to avoid developmentally appropriate participation in sports activities. What we 

need to do is focus on how to teach recognition and response, and 

our country needs a good universal mechanism to implement community focused youth concussion solutions, and we believe that 

that can help children ultimately as they enjoy the benefits of 

sports. 

Our SCORE motto applies here. It says, ‘‘Play hard, play safe, 

but play smart.’’ 

Thank you. 

[The prepared statement of Mr. Gioia follows:] 

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Mr. TERRY. Very good. Dr. Shenton, you are now recognized for 

your 5 minutes. 

STATEMENT OF MARTHA E. SHENTON 

Ms. SHENTON. Thank you. I want to thank Chairman Terry, 

Ranking Member Schakowsky, and members of the subcommittee. 

I am honored to be here today. 

My focus is going to be on radiological evidence of both concussion and subconcussive blows to the head. And if I could have the 

next slide. 

What is known is that mild traumatic brain injury is common in 

sports injury, and when we are talking about a single mild TBI, 

about 80 percent get better, between 15 and 30 percent go on to 

have persistent concussive symptoms, as have been described 

today. 

What is most concerning though are what has been called chronic traumatic encephalopathy and other neurodegenerative disorders, and that is the second one where it is repetitive mild traumatic brain injury that we are really concerned with. And the 

clearest evidence comes from postmortem studies. 

If I could have the next slide? Here is a postmortem slide. This 

is Ann McKee’s work that shows how protein in the brain, and 

those are the brown areas that show up. And this is in a case of 

a retired professional football player who had symptoms, and was 

presumed to have chronic traumatic encephalopathy, which was 

confirmed at postmortem. 

Next slide, please. Now, here are four individuals, A, B, C, and 

D. What is interesting here, and this is work by Goldstein, it shows 

that blast injury and repetitive brain trauma look the same at 

postmortem. So we have a military person at 45 with one closerange blast injury, a 34-year-old with two blast injuries, an amateur football player at the age of 18 with repetitive concussions, 

and then a 21-year-old with subconcussive blows to the head only. 

Next slide please. So what is known? We have gone over the first 

two. The third is mild TBI is very difficult to diagnose, and that 

has been a really serious problem because if you use conventional 

CT and conventional MRI, you are not likely to find differences or 

abnormalities in the brain, and so many people have said there is 

no problem then. The problem is the correct advanced tools have 

not been used until more recently. And now with advanced 

neuroimaging, we are able to both diagnose and move towards 

prognosis and hopefully intervention. Advanced neuroimaging techniques such as diffusion imaging, which we have been using in our 

laboratory, show radiological evidence of brain alterations in living 

individuals with mild TBI. And so if we can detect this early, and 

we can perhaps then look at underlying mechanisms and characterize what is going on in order to come up with preventative measures. 

Next slide, please. So this is a study from our group, looking at 

hockey players from university hockey players in Canada. And the 

bottom line is over on the right. The first is at preseason and the 

second is at postseason. The red dots are three individuals who had 

concussion during play, from preseason to postseason. And the inVerDate Mar 15 2010 15:08 Jul 22, 2015 Jkt 037690 PO 00000 Frm 00157 Fmt 6633 Sfmt 6633 F:\113THCONGRESS\113128SPORTSSAFETYASKOK060515\113128SPORTSSAFETYPDF
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1 Additional information has been retained in committee files and also is available at http:// 

docs.house.gov/meetings/IF/IF17/20140313/101897/HHRG-113-IF17-Wstate-ShentonM20140313-SD001.pdf. 

crease is increase in extra cellular water in the brain, which is not 

a good sign. 

Next slide, please. We also looked at brain matter, looking at cortical thinning in the brain, and that is the cortex where neurons 

are in the brain. And this is a study in former professional football 

players who were symptomatic when we looked at them. And what 

we found was that there is cortical thinning compared to agematched normal controls. What is most concerning, however, is 

that blue line that shows that the cortical thinning accelerates with 

age, whereas the red line, our control group, where it is almost 

completely flat. And this suggests that cortical thinning may indicate abnormal aging and a risk for dementia that we can see right 

now in living individuals. 

Next slide, please. Now, this is a study that we did in Germany 

with elite soccer players, and we selected them specifically for not 

having a history of concussion, and not having any symptoms 

whatsoever. And what we found was, compared to professional 

swimmers, there was a huge difference between the two groups, 

with the controls on the left and the soccer players on the right. 

Almost a complete separation between the two groups, with an increase in what is called radial diffusivity, which is a measure of 

damage to myelin in the brain. 

Next slide please. So what we don’t know: Why do concussive 

and subconcussive trauma result in some and not in others? Another question we don’t know is, Why do some develop 

neurodegenerative disease while others do not? What are the predisposing factors? Is exposure or genetics involved, because not 

every football player, not every soccer player, not every hockey 

player who plays and gets hit to the head ends up with these 

neurodegenerative diseases, which is what, I think, people are most 

concerned with. 

And next slide. So what we need is diagnosis to detect brain injury early. We have imaging tools now that are sensitive, widely 

available, and can be applied in vivo, prognosis to follow recovery 

and degenerative processes. So we need to follow recovery and degenerative processes in order to predict who will have a poor outcome, and who will have a good outcome. And knowing that, we 

might be able to intercede with treatment to halt the possible cascade of neurodegenerative changes. 

And finally, just in summary, next slide. Sports concussion leads 

to alterations of the brain’s white and gray matter. Advanced 

neuroimaging is sensitive to detect brain alterations following concussion and subconcussive brain trauma, and the impact over time 

is important. We need longitudinal studies to identify different 

stages of recover, and being able to pick out ahead of time what 

is going to lead to a poor outcome so that we can intercede. 

And finally, some measures of safety, such as rules for returning 

to play are needed following observable evidence of brain trauma. 

Thank you. 

[The prepared statement of Ms. Shenton follows:] 1

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Mr. TERRY. Thank you. Very impressive testimony from everyone, and I was even impressed that you all stuck to the 5 minutes, 

pretty close. 

Now, I am going to go back to Dr. Molfese because I think your 

testimony and Dr. Shenton’s kind of juxtapose each other here very 

nicely. 

So part of what your research is doing is finding that baseline 

of the new athletes that enter University of Nebraska. So is this 

allowing you to detect the injuries earlier, that there may have 

been some pre-existing subconcussion? How are you identifying 

that, what is it telling you, and what is the university doing to implement some level of protections? 

Mr. MOLFESE. Well, one of the major changes we have seen, and 

I think this is occurring across the field now, is the effort to get 

pre-concussion data. So basically, more and more schools are moving to assess student athletes prior to the start of the season, and 

that certainly is what we are doing. And then should a player be 

injured, and they are identified through trainers or the medical 

team. One of the weaknesses here is that the players do not always 

self-identify, and so we have run across that a number of times in 

our testing, or we will pick up something on our test the trainers 

and the medical team didn’t know about simply because the player 

didn’t disclose. And then we also try to test somebody else who 

plays a similar position but has not been injured, and they act sort 

of as a game control over the course of a season. And generally, 

what we are finding is both effects that occur across the season and 

just our normal players who have no history of concussion being 

identified, their brain speed of processing does change over the 4 

to 5 months of training and the season, but then with the players 

who are—who do experience a concussion, we see, in terms of brain 

electrical activity, again, the slowdown of about 200 milliseconds. 

That is four times faster than the slowdown you see in Multiple 

Sclerosis, for an example, for a contrast. So clearly, the brain has 

changed the way it is processing. 

We are just now moving to start intervention programs with the 

players that we identify. There is some data out there with early 

Alzheimer’s that suggest working memory-type tasks may take 

even a week of intervention, shows a 4-to-5-week continual gain in 

improvement, and so we are trying to see if we can see some of 

that occurring. 

Mr. TERRY. Thank you. 

Dr. Gay, in regard to concussions, though many times it is not 

a direct blow, but coup contra coup, it is being hit so that the head 

is going back and forth, and the brain is sloshing around. 

You mentioned going back to 1970s type of equipment, and Tom 

Osborne likes to talk about the neck roll. Describe to me what you 

mean by 1970s equipment, and how it may actually reduce concussions. 

Mr. GAY. Thank you, Mr. Chairman. 

Yes, the neck roll, what I call a horse collar, is really a piece of 

equipment that has disappeared from the game. And it does an important thing, it essentially immobilizes the head. So if concussions 

are incurred by the rattling of the brain back and forth, especially 

from a blow to the side, the horse collar will substantially damp 

171 

that down. To my knowledge, there are no epidemiological studies 

of that being effective, but my personal opinion, even though I am 

largely ignorant of medical science, is that if you immobilize the 

head, that is going to solve a lot of the problems, especially with 

these rotational hits. Yes. 

Mr. TERRY. Dr. Graham, does that make sense? 

Mr. GRAHAM. I think whether or not the horse collar would have 

that effect, I don’t know, and, of course, our committee was based 

purely on science and, you know, reviewing the literature, but I 

think the principle is, you want to find ways to minimize the linear 

and rotational forces that come into effect with a blow to the head, 

and whether you can do that by equipment, whether you can do 

that by change in play, you know, that is what you have to do to 

decrease the incidence of concussion. 

Mr. TERRY. Thank you. I only have 11 seconds left, so I will yield 

back and recognize the Ranking Member, Ms. Schakowsky. 

Ms. SCHAKOWSKY. You know, in addition to the science, so much 

talk has been about culture, and it seems to me that that is very 

important. So a change in the culture means not only managing 

head injuries when they occur, but also encouraging safer play to 

reduce the risk of head injuries. 

So, Mr. Heaton, you spoke about the need to change the, I am 

quoting from your testimony, ‘‘the win at all cost’’ attitude among 

players and coaches. What would you tell teams to help them 

change that attitude, both within themselves and teammates, and 

perhaps more challenging, in coaches? 

Mr. HEATON. Thank you. Well, frankly, I would actually encourage the coaches to stress this as much as possible, as well as the 

parents, because the coaches and the parents are there to help us 

learn how to play these sports correctly, and if they can emphasize 

not having to worry about winning to the point where you get hurt, 

then it will trickle down to the players, and then the players become coaches, and then it is this never-ending cycle of teaching and 

making sure that the players know that winning is not the most 

important thing. You know, it feels great to win, but I would much 

rather lose than have another concussion. 

Ms. SCHAKOWSKY. Clearly, you were aware because of the severe 

consequences of the brain injury, but do you think that youth athletes understand what those symptoms are? 

Mr. HEATON. Yes. I think it is getting better, indeed, especially 

in my school. I mean we emphasize making sure that you know the 

symptoms of concussions, and I feel like it is spreading as well, but 

I—— 

Ms. SCHAKOWSKY. Let me ask Dr. Gioia that, too. 

Mr. HEATON. OK. 

Mr. GIOIA. Yes, certainly, at this point, the education programs 

are also being directed toward the athletes, and quite honestly, 

about 5 years ago, maybe 6 years ago, there was a study that 

showed that that was the number 1 reason why athletes were not 

coming out of the game, because they didn’t know how to tie together the symptomatology. It wasn’t simply that they didn’t want 

to lose playing time, but they didn’t know what they were dealing 

with in themselves. 

Ms. SCHAKOWSKY. Right. 

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Mr. GIOIA. But we also believe that athletes and teammates need 

to watch out for each other, because the concussed athlete themselves may not have the wherewithal to know that they aren’t 

right, and yet their teammate right next to them oftentimes does. 

So there is a responsibility within that team to take care of each 

other, and that is an important focus. 

Ms. SCHAKOWSKY. And that goes to culture as well. 

Mr. GIOIA. Yes, absolutely. 

Ms. SCHAKOWSKY. Yes. Yes. 

Dr. Shenton, please explain a little bit how advanced 

neuroimaging works, and describe the types of changes in the brain 

your lab is able to detect that traditional imaging can’t, and also 

some of the types of neuroimaging used by your lab have been a 

significant part of the research on diseases like Alzheimer’s and 

schizophrenia. Why are the same imaging techniques appropriate 

for research on these diseases and research on sports-related brain 

injuries? 

Ms. SHENTON. OK, I have a slide, which is just at the end of my 

slides, that just explains in one slide diffusion imaging, which I 

think would help out here. 

Ms. SCHAKOWSKY. The one slide I really didn’t understand was 

comparing swimmers with—— 

Ms. SHENTON. With soccer players—— 

Ms. SCHAKOWSKY. Right. 

Ms. SHENTON [continuing]. But I was going to go through—— 

Ms. SCHAKOWSKY. All right, go ahead. 

Ms. SHENTON [continuing]. And just show you—— 

Ms. SCHAKOWSKY. OK. 

Ms. SHENTON [continuing]. Why diffuse external injury is important because the injury that happens in the impact to the brain is 

generally a stretching of the cables in the brain, which is really the 

white matter, and for example, the corpus callosum is the largest 

white matter track in the brain, and so you get sharing. And this 

doesn’t show up on tradition CT or MRI. In fact, the first mild TBI 

conference I went to, no one showed a brain. And I looked to my 

colleague and I said why would no one show a brain. And he said 

because everyone knows that you can’t see anything on the brain. 

And I said, but then nobody is using the right tools here. 

And this is just a very simple principles of diffusion imaging. If 

you look on the left, this is ink that goes on a Kleenex. It goes in 

all directions, and that is called isotropic diffusion. If you look on 

the right, it says anisotropic diffusion. So you are dropping ink on 

newspaper, and newspaper has fibers so it restricts the water. And 

this is the same principle that is used quantitatively to look at the 

brain, so that, if you are in CSF, it is very round, and it is isotropic, everything goes in the same direction. If you are looking at 

white matter, you are restricted in 2 directions, and so you can 

measure what the integrity is of white matter fiber bundles in the 

brain. And that is what you need to look at in mild TBI. 

Now, if you have someone come in with a moderate or severe 

brain injury, you don’t need this kind of technology. 

Ms. SCHAKOWSKY. Uh-huh. 

Ms. SHENTON. They are going to just be put into neurosurgery, 

and they are going to do an operation. It is these very subtle brain 

173 

injuries that aren’t recognized using conventional imaging, where 

you can recognize it if you use something like diffusion imaging. 

And we have shown over and over again now that you can see— 

and it is not just our group. Starting in 2003, people started using 

diffusion imaging because it is the most sensitive imaging tool that 

exists today to look at diffuse external injury, which is the major 

injury in mild TBI. 

So what needs to be done now is to look at acute injury, and see 

what predicts outcome, like do acute injury at 72 hours, at 3 

months, at 6 months. Can we then predict, knowing that what happens at 72 hours, if we have someone in our lab that is trying to 

separate water that is outside cells versus in cells. If you can predict from 72 hours, then you can go back and say, OK, maybe we 

want to put in anti-inflammatory medications if this is a 

neuroinflammatory response. 

We don’t know enough right now. The only way to know is to do 

these longitudinal studies, and follow over time using very sophisticated imaging technology, in my opinion. Once you know, you can 

diagnose. Once you diagnose, you—— 

Ms. SCHAKOWSKY. So this could be very promising—— 

Ms. SHENTON. Yes. 

Ms. SCHAKOWSKY [continuing]. Not only for our athletes, but our 

returning veterans and—— 

Ms. SHENTON. Yes. 

Ms. SCHAKOWSKY [continuing]. Applied eventually to schizophrenia or Alzheimer’s? 

Ms. SHENTON. Well, actually, we have applied—I am primarily 

schizophrenia research, that is—— 

Ms. SCHAKOWSKY. OK. 

Ms. SHENTON [continuing]. What I have done for 30 years before 

I became a TBI researcher in 2008. And we have a measure called 

free water, this kind of imaging that shows that early on at the 

very first episode of schizophrenia, you see fluid around all of the 

brain that is free water, it is isotropic, but in just the frontal lobe, 

you see it more restricted to inside tissue. And this is a brand new 

technique that was developed by a Fulbright Scholar that is in our 

lab from Israel. And so—— 

Ms. SCHAKOWSKY. OK, I am going to have—— 

Ms. SHENTON. OK. 

Ms. SCHAKOWSKY [continuing]. To say thank you—— 

Ms. SHENTON. Fair enough. 

Ms. SCHAKOWSKY [continuing]. Because it is very promising. 

Mr. TERRY. Two and a half. 

Ms. SCHAKOWSKY. Thank you. 

Mr. TERRY. Yes, thank you. 

Gentleman from New Jersey is recognized. 

Mr. LANCE. Thank you, Mr. Chairman. 

Dr. Johnston, you stated that many sports-related concussions 

still go undiagnosed, and I would like to know why, in your opinion, that is the case, and how can we improve that in our State 

laws, and also the involvement of coaches and players and PTAs, 

areas where we need to have improvement? 

Mr. JOHNSTON. Thank you for the question. 

174 

I think I would echo what has been said by others on the panel. 

It is on. It is on. Sorry. I would echo what has been said by others 

on the panel, that I think that a lot of it has to do with recognition. 

Obviously, people are very good at recognizing when someone gets 

knocked out on the field, but, of course, that is a very small percentage of all concussions, and I think that as our understanding 

of all the various symptoms that can go with concussion have arisen, it becomes incumbent upon us to improve the quality of the 

education that we give to our coaches, players, trainers, officials, 

about the symptoms of concussion. I think that that is the main 

reason. My sense is that, in general, the culture, at least speaking 

for the State of Alabama, that all the coaches that I have come into 

contact are believers, they are not, you know, purposefully hiding, 

you know, kids and putting them back in knowing they have concussions, but I think that sometimes it is hard to recognize, especially when young athletes don’t tell you how they are feeling, and 

other issues which I guess were brought up with the importance 

of teammates being involved with diagnosing these players so they 

can be pulled and appropriately evaluated. 

Mr. LANCE. How close, in your opinion, are we to a better design 

for helmets? 

Mr. JOHNSTON. I think that we are at the very beginning. I think 

that we have been using a standard that has not changed for 40 

years, that was designed for skull fractures—— 

Mr. LANCE. Yes. 

Mr. JOHNSTON [continuing]. That has served its purpose, and I 

think that many investigators around are working to improve the 

quality of the standards to include linear and rotational acceleration, as well as other important aspects of impacts. And just like 

the automotive industry did 30 years ago with, once you start ranking cars with safety ratings, the market can be relied upon for 

manufacturers to improve their helmet designs to improve their 

sales. So I think that is the stage we are at. I think standards are 

an important part of the equation. 

Mr. LANCE. Thank you. 

Dr. Gay, in your testimony, you have discussed the fact that 

there is a numerical rating system for a helmet’s impact, I think 

it is designed at Virginia Tech, the Star System, and you have 

called it the best tool we have for analyzing the merits of various 

helmet systems. 

Can you briefly explain how the numerical scoring system works? 

Mr. GAY. Yes, thank you, Mr. Vice Chairman. 

Basically, it involves a test where you drop the helmet from a 

given height, a varying height, to the side, to the front, to the back. 

It tries to simulate the kinds of impacts that a football player 

would actually experience, and numerical scores are given to the 

maximum acceleration that the NOCSAE head inside the helmet 

feels for these given drops, based on a, in my opinion, fairly crude 

initial model of what causes concussions. There is no effect to take 

into account rotation, there is no effect of temperature, and, in my 

opinion, the reproducibility is not as good as one would like, having 

tried to do examples of these kinds of tests in groups that I have 

been involved with. 

175 

So I think it is a good first start. It is the best we have right 

now. I think it needs to be paid attention to, but there is a lot of 

room, a lot of room for improvement. 

Mr. LANCE. Thank you, Dr. Gay. 

And finally, Ian. How old are you and what grade are you in? 

Mr. HEATON. I am 18 and I am a senior. 

Mr. LANCE. And does that mean you will be going off to college 

in the autumn? 

Mr. HEATON. Yes—— 

Mr. LANCE. And—— 

Mr. HEATON [continuing]. I will. 

Mr. LANCE. And do you know yet where you will be attending 

college? 

Mr. HEATON. I am going to Elon University in North Carolina. 

Mr. LANCE. In North Carolina. My congratulations to you, and 

my condolences to your parents on the cost of higher education in 

this country. It is a great school. I have a goddaughter who is a 

freshman there. That means she is a little older than you, but I 

will be happy to introduce you to her. 

And let me say, I am very proud of your testimony, and I could 

not have done what you have just done when I was 17 or 18, and 

certainly, I think the Nation has benefitted by your outstanding 

testimony. 

Mr. HEATON. Thank you. 

Mr. LANCE. Thank you. 

Mr. TERRY. Gentleman from Mississippi, you are now recognized 

for 5 minutes. 

Mr. HARPER. Thank you, Mr. Chairman. And thank each of you 

for being here and sharing your expertise on what is a topic that 

we are really just learning about, as it has been in the news for 

several years, but it is, I think coming to the forefront. And your 

work and your information, your testimony on the record here 

today I think will be beneficial to us. 

As a parent of a 24-year-old young man with Fragile X Syndrome, I particularly appreciate the work that you do at the Children’s Hospital, you, Dr. Gioia, you, Dr. Johnston, but in preparation for this, I had some discussion with some parents back home, 

and the interesting discussion is I had several friends who have 

daughters playing youth soccer, and a number of them reported an 

increase in the number of concussions suffered by young ladies 

playing youth soccer. You know, we seem in the news to always associate it with NFL, and helmet-to-helmet contact, and concussions 

and things that we see on the field of play, but it appears in everything we do in life, every sporting event, there is that danger and 

that risk. That is why, I think, what you are doing with the Think 

First Alabama, Dr. Johnston, the preventive part of it is how do 

we educate our players and coaches, parents, and perhaps, using 

the teammate approach, the safest thing may be to have the 

backup position player be the one to report for the first teamer 

when they need to come out, you know, that might get them off the 

field. But thank each of you for your work. 

And, Dr. Johnston, educate just a little bit on what is a subconcussive impact? What does that mean, and how important is 

176 

that when addressing concussion diagnoses, and should subconcussive impacts affect rules of game and play, and if so, how? 

Mr. JOHNSTON. Yes, so I think that the definition of a subconcussive impact would be all those other, the 99.9 percent of impacts 

that happen that don’t result in a concussion, meaning a diagnosed 

concussion. And as has been pointed out previously, the rub with 

concussion is the diagnosis part. If you look at some of our historical studies about rates of concussion in different sports, it is very 

variable, and a lot of that has to do with who is diagnosing it and, 

you know the, you know, males versus females, whether or not men 

are more likely to report or less likely to report symptoms. But I 

think that a subconcussive impact is all those other impacts that 

we have found more and more information with the important imaging that has been done in Boston and other places, that even 

these subconcussive impacts have results in terms of anatomic, you 

now, structural changes in the brain over time. 

So I think that the subconcussive impact needs to be addressed 

in terms of lessening the overall cumulative impact load that every 

player has. Football is kind of the most obvious thing—— 

Mr. HARPER. Right. 

Mr. JOHNSTON [continuing]. In terms of player practices and how 

many practices a week children should be able to do hitting and 

whatnot, but I think that has applications for all sports. 

Mr. HARPER. OK, thank you. 

And, Dr. Molfese, if I could ask you a question. Just for clarification first, if I could ask, the 77 percent of military that—— 

Mr. MOLFESE. Yes. 

Mr. HARPER [continuing]. That figure, is that how many of TBI 

cases have suffered concussions, or is that 77 percent of all military? I wasn’t quite—— 

Mr. MOLFESE. That is of traumatic brain injuries—— 

Mr. HARPER. OK. 

Mr. MOLFESE [continuing]. Seventy-five to 77 percent are concussions, mild TBIs. 

Mr. HARPER. I gotcha, OK. And can you tell us more about the 

sideline imaging work that you are doing? You know, is this practical, is this something that we can expect to see rolled out to sidelines across America to diagnose our athletes, and perhaps how 

about onto battlefields to diagnose our warriors? 

Mr. MOLFESE. I think it is very possible. We have actually already published a paper just this last year in 2013, where we took 

one of our EEG systems and recorded on the sideline of a field. The 

biggest challenge for us in making it practical is to get the processing time down. At this point, it takes us an hour. If we can get 

it down to 5 minutes, then I think we can sell it to the coaches, 

because they are the ones really that are going to determine. 

And I guess at this point, given all the other issues, the common 

tests we use right now are like the SCSI 3 and the impact, which 

are some neuropsych assessment tools, sort of questions to the 

player, and they have to reflect and they may be a little foggy because of the concussion, but these tests don’t have any predictability or reliability after 2 days post-injury. That is our big problem. It doesn’t predict recovery time, it doesn’t predict the severity 

of the injury, and so on. So these biomarkers that we all are talkVerDate Mar 15 2010 15:08 Jul 22, 2015 Jkt 037690 PO 00000 Frm 00180 Fmt 6633 Sfmt 6633 F:\113THCONGRESS\113128SPORTSSAFETYASKOK060515\113128SPORTSSAFETYPDF
177 

ing about are really the critical things that we are hoping are going 

to be much more reliable, more predictive. 

Mr. HARPER. Thank you very much. And thank each of you for 

being here. 

And I yield back. 

Mr. TERRY. Thank you. And, generally, this would end, but we 

all have so many questions, we are actually going to do a second 

round, and plus the bells aren’t going to go off for at least another 

7 minutes. Jan does have a conflict, and she has given us approval 

that she is going to leave, but she trusts us to ask legitimate questions. 

Ms. SCHAKOWSKY. But let me just really thank this panel, the 

previous panel as well, but the intensity now of the scientific research and then its application to the playing field, and actually so 

many other fields, I really want to thank you for telling us what 

is going on. And I also did want to thank Ian Heaton for coming 

here today. I think it is important to have people like Briana and 

Ian to tell their stories, and give us a face to the importance of this. 

I want to thank the FTC too for making sure that false claims 

aren’t made, but this is so important, so appreciated, and then we 

will have to figure out where it leads us, but it certainly has informed us. Thank you. 

Mr. TERRY. Yes. I would agree with every word of that. 

So this is a question to you, Dr. Molfese, and Dr. Shenton, and 

it dovetails into what the gentleman from Mississippi was talking 

about as well, but are the symptoms of a concussion or TBI uniform enough so that it is possible for early detection or developing 

a checklist for a coach or a parent to be used, you know, by nonmedical? We will start with you, Dr. Shenton. 

Ms. SHENTON. No. The symptoms—— 

Mr. TERRY. Well, that was easy. 

Ms. SHENTON. The symptoms overlap with depression and PTSD, 

and that has been a real problem. In fact, there was a paper published in The New England Journal of Medicine that said when you 

remove the effects of depression, and you remove the effects of 

PTSD, mild TBI doesn’t exist. And that is a real disservice, and it 

used to be that people would claim that when people came in complaining that they still had symptoms from hitting their head, since 

there was no evidence from conventional MRI or conventional CT, 

they said go see a psychiatrist. So it was really not appropriate at 

all, because there is at least a small minority of people who have 

mild concussion who go on to have symptoms, and they can go on 

for months, for years, and then they can clear up. So that is separate even from CTE. 

What you need is radiological evidence for diagnosis, the same 

way you would want to know values of a blood test for cholesterol 

or a broken leg. And I think we are moving in that direction, and 

that is what we need is the hard evidence—— 

Mr. TERRY. OK. 

Ms. SHENTON [continuing]. Because the symptoms are too nonspecific. 

Mr. TERRY. All right. Dr. Molfese? 

Mr. MOLFESE. There are actually studies published looking at the 

number of symptoms, and a wide variety of a number of symptoms 

178 

people will report. There is no data that indicates whether somebody reports lots of symptoms versus a few symptoms, that that 

has any relation to how long they are going to recover, how serious 

the injury is, how great the impairment is—— 

Mr. TERRY. Right. 

Mr. MOLFESE [continuing]. Unfortunately. 

Mr. TERRY. So can we get to the point where the seventh grader 

takes a big hit, that there is a checklist, per se, that the coach 

could use to determine if that kid should go back into the game? 

Mr. MOLFESE. Well, I think in general, there certainly are guidelines out by the CDC and others that list concussion symptoms. 

And so I think the general bias at this point is if the individual 

reports any of these symptoms, that they should be pulled, because 

we do know that there is data to indicate that if you do have a concussion and then you start playing again before the symptoms resolve, the likelihood of even death is much greater. 

Ms. SHENTON. Um-hum. 

Mr. TERRY. All right. 

Mr. MOLFESE. Not to mention further significant concussion that 

is going to take longer to recover. 

Mr. TERRY. All right. So this one is for Dr. Johnston and Dr. 

Gioia. 

One of the debates that is occurring in the State of Nebraska 

right now is you have a child, all right, a high school student that 

suffers a concussion during a game. So it has been diagnosed. What 

do you do next? Right now, the thought is you keep him home or 

her home, dark, no electronics. That is kind of the norm. There is 

a discussion whether that is appropriate or not, or to what length. 

What do you know? What would you recommend? 

Mr. JOHNSTON. Well, I will tell you about how we handle things 

in Alabama, and I think a lot of what we do is based on the CDC 

Guidelines and the Zurich Guidelines, which is that once an athlete 

is diagnosed, they are removed from the field of play, and then 

they are evaluated. We use the SCAT, which is the sports concussion assessment tool, which is a sideline-based assessment. We also 

use it afterwards as well. It has kind of a quick mini inventory of 

neurological exam and neurocognitive function. And then when 

children have symptoms that persist, you know, obviously, they 

don’t return to any sort of play or even an escalation of activity 

until their symptoms have completely resolved. And then those 

children who have persistent symptoms lasting beyond the 1 to 2 

weeks are then referred to neuropsychologists, like Dr. Gioia, and 

a traumatic brain injury program. 

So I guess I would defer to you for—— 

Mr. TERRY. What would you recommend—— 

Mr. GIOIA. Yes. 

Mr. TERRY [continuing]. Dr. Gioia? 

Mr. GIOIA. Yes. This is a big question at this point. This really 

comes to what is the best treatment for this injury. And let me just 

say, the field is moving on this one, and the recommendations that 

we make, and I have written several recent papers on this, is that 

in that acute stage of symptoms, probably the first few days, maybe 

for some a little bit longer if there is a more severe number of 

symptoms, is that they really reduce their activity, cognitive and 

179 

physical. But what you want to be doing though is start to increase 

that activity over time. So we don’t black box kids until they are 

asymptomatic. That has a lot of likely negative effects on kids, obviously, being removed. 

So what we do is we initially shut them down, restrict them, 

then we gradually start to bring them back into school and into 

physical activity, but that has to be individualized based, again, on 

the severity of that symptom presentation. And that is where we 

are right now. We need a whole lot of research to really help validate that. 

Mr. TERRY. Thank you. And, Mr. Lance? 

Mr. LANCE. No questions. 

Mr. TERRY. Gentleman from Missouri gets to ask another question. 

Mr. HARPER. Mississippi. 

Mr. TERRY. Mississippi. 

Mr. HARPER. No, I was just looking down. 

Mr. TERRY. Yes, I thought you were Billy Long. 

Mr. HARPER. That hurt. That hurt. Thank you, Mr. Chairman. 

And a couple of questions that I would have. One would be, Dr. 

Gay, if I may ask a question? 

Mr. GAY. Yes, sir. 

Mr. HARPER. In your testimony, you state that football players at 

the elite levels are shedding equipment to increase speed and mobility. 

Mr. GAY. Yes. 

Mr. HARPER. The decision of which helmet to wear is their own, 

and that player often chooses a helmet’s looks, shape, feel, perhaps, 

over its collision cushioning ability or safety features. 

Do some positions require different levels of collision cushioning, 

and if so, would you recommend a special helmet for specific positions that would meet all current safety standards? 

Mr. GAY. Yes, that is a great question. 

Currently, there are no position-specific helmets being made. I 

think the helmet manufacturers try to do the best they can for everybody. I would say that, not to belabor the point, but I think for 

linemen, where you typically get no severe hits but a lot of subconcussive blows, that horse collar is crucial. I wouldn’t recommend 

that a wideout wear a horse collar. That would really affect the 

quality of the play. 

It is an interesting point because, certainly, some players might 

tend—and this is why I am an advocate for the Hits System. It will 

give us much more detailed information about which positions get 

hit where. One could envision, if we have a large database, then 

improving helmet design to react to that kind of information. 

Mr. HARPER. OK. Dr. Graham, if I could ask you. How much 

money has been spent on sports concussion research, and where is 

most of the funding coming from for that research? 

Mr. GRAHAM. That, unfortunately, was not an issue that our 

committee looked at, nor would we have had the resources to, you 

know, to pull it out. 

Mr. HARPER. Sure. 

Mr. GRAHAM. But, you know, clearly, you can identify some research that is being done in the Federal sector that applies to this, 

180 

but the private research that may be done by the sports leagues, 

by the manufacturers of equipment themselves, I don’t know any 

good way to quantify that for you. 

Mr. HARPER. Gotcha. All right. Well, look, I appreciate everybody 

being here, and it is a very important issue. We love our children 

going through sports, we love to watch it, and we don’t want anybody being hurt that shouldn’t be hurt. And so, hopefully, this increased focus will lead to better research, better safety equipment, 

detection, and, of course, prevention. 

So thank you very much. Thank you, Mr. Chairman. I yield back. 

Mr. TERRY. Thank you, the gentleman from Mississippi. 

Mr. HARPER. Thank you. 

Mr. TERRY. And I just want to thank all of you. This was truly 

an all-star panel of medical experts and physics. And much appreciated, Ian. Thank you. 

And so that does conclude our hearing for today. 

Now, for our witnesses, we, whether we showed up or not, have 

the right to send you a question, and it is called a written question. 

We have about 14 days to write those and submit them to you, and 

I appreciate a couple of weeks, not over, you don’t have to do it 

right away, but at least if you can get them back to us, if there 

are any, within about 14 days. 

And I just, again, want to thank you for coming out here and 

providing some very, very valuable testimony for us. 

And we are adjourned. 

[Whereupon, at 1:27 p.m., the subcommittee was adjourned.] 

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