```

[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]

 
                       THE IMPACT OF CONCUSSIONS
                        ON HIGH SCHOOL ATHLETES:
                         THE LOCAL PERSPECTIVE

=======================================================================

                             FIELD HEARING

                               before the

                        SUBCOMMITTEE ON HEALTHY
                        FAMILIES AND COMMUNITIES

                              COMMITTEE ON
                          EDUCATION AND LABOR

                     U.S. House of Representatives

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

             HEARING HELD IN SELDEN, NY, SEPTEMBER 13, 2010

                               __________

                           Serial No. 111-74

                               __________

      Printed for the use of the Committee on Education and Labor

                       Available on the Internet:
      http://www.gpoaccess.gov/congress/house/education/index.html

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                    COMMITTEE ON EDUCATION AND LABOR

                  GEORGE MILLER, California, Chairman

Dale E. Kildee, Michigan, Vice       John Kline, Minnesota,
    Chairman                           Senior Republican Member
Donald M. Payne, New Jersey          Thomas E. Petri, Wisconsin
Robert E. Andrews, New Jersey        Howard P. ``Buck'' McKeon, 
Robert C. ``Bobby'' Scott, Virginia      California
Lynn C. Woolsey, California          Peter Hoekstra, Michigan
Ruben Hinojosa, Texas                Michael N. Castle, Delaware
Carolyn McCarthy, New York           Vernon J. Ehlers, Michigan
John F. Tierney, Massachusetts       Judy Biggert, Illinois
Dennis J. Kucinich, Ohio             Todd Russell Platts, Pennsylvania
David Wu, Oregon                     Joe Wilson, South Carolina
Rush D. Holt, New Jersey             Cathy McMorris Rodgers, Washington
Susan A. Davis, California           Tom Price, Georgia
Raul M. Grijalva, Arizona            Rob Bishop, Utah
Timothy H. Bishop, New York          Brett Guthrie, Kentucky
Joe Sestak, Pennsylvania             Bill Cassidy, Louisiana
David Loebsack, Iowa                 Tom McClintock, California
Mazie Hirono, Hawaii                 Duncan Hunter, California
Jason Altmire, Pennsylvania          David P. Roe, Tennessee
Phil Hare, Illinois                  Glenn Thompson, Pennsylvania
Yvette D. Clarke, New York           [Vacant]
Joe Courtney, Connecticut
Carol Shea-Porter, New Hampshire
Marcia L. Fudge, Ohio
Jared Polis, Colorado
Paul Tonko, New York
Pedro R. Pierluisi, Puerto Rico
Gregorio Kilili Camacho Sablan,
    Northern Mariana Islands
Dina Titus, Nevada
Judy Chu, California

                     Mark Zuckerman, Staff Director
                 Barrett Karr, Minority Staff Director
                                 ------                                

            SUBCOMMITTEE ON HEALTHY FAMILIES AND COMMUNITIES

                 CAROLYN McCARTHY, New York, Chairwoman

Yvette D. Clarke, New York           Todd Russell Platts, Pennsylvania,
Robert C. ``Bobby'' Scott, Virginia    Ranking Minority Member
Carol Shea-Porter, New Hampshire     Howard P. ``Buck'' McKeon, 
Paul Tonko, New York                     California
Jared Polis, Colorado                Brett Guthrie, Kentucky
George Miller, California            David P. Roe, Tennessee
Judy Chu, California                 Glenn Thompson, Pennsylvania

                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on September 13, 2010...............................     1

Statement of Members:
    Bishop, Hon. Timothy H., a Representative in Congress from 
      the State of New York......................................     4
    McCarthy, Hon. Carolyn, Chairwoman, Subcommittee on Healthy 
      Families and Communities...................................     1
        Prepared statement of....................................     3
        Additional submission: Liz Giordano, chief executive 
          officer, Head Injury Association, prepared statement of    39

Statement of Witnesses:
    Caster, Richard C., former NFL football player...............    22
        Prepared statement of....................................    24
    Hall, Courtney, former NFL football player; cofounder, 
      Hillcrest Venture Partners.................................    25
        Prepared statement of....................................    27
    LoNigro, Craig, M.S., ATC, athletic trainer, Comsewogue High 
      School.....................................................    11
        Prepared statement of....................................    15
    Monaghan, Caitlin, former high school athlete................    18
        Prepared statement of....................................    21
    Queller, Hayley C. Rintel, M.D., primary care sports 
      medicine, Orthopedic Associates of Long Island.............     8
        Prepared statement of....................................    10

                   THE IMPACT OF CONCUSSIONS ON HIGH
                 SCHOOL ATHLETES: THE LOCAL PERSPECTIVE

                              ----------                              

                       Monday, September 13, 2010

                     U.S. House of Representatives

            Subcommittee on Healthy Families and Communities

                    Committee on Education and Labor

                             Washington, DC

                              ----------                              

    The subcommittee met, pursuant to call, at 11:10 a.m.,at 
Suffolk County Community College, Ammerman Campus Selden, New 
York, Hon. Carolyn McCarthy [chairwoman of the subcommittee] 
presiding.
    Present: Representative McCarthy.
    Also present: Representative Bishop of New York.
    Staff Present: Helen Pajcic, Associate-Education Policy; 
Joanna Serra, office of Representative Bishop; and Kim Zarish-
Becknell, Policy Advisor.
    Chairwoman McCarthy. A quorum is present. The hearing of 
the House Committee on Education and Labor Subcommittees on 
Healthy Families and Communities on the Impact of Concussions 
on High School Athletes: The Local Perspective will come to 
order.
    Before we begin I would like everyone to take a moment to 
ensure that your cell phones and Blackberrys are on silent.
    I now recognize myself followed by Congressman Bishop for 
an opening statement.
    I would like to welcome our witnesses to this hearing on 
student concussion safety.
    As a nurse for over 30 years, I have seen firsthand the 
damage that can occur as a result of concussions in our young 
people.
    Today we will examine how concussions, experienced by high 
school athletes on the playing field, are impacting their 
academic well-being and their quality of life.
    We will also learn more about how schools and the medical 
community can provide appropriate management and support for 
these young athletes.
    One of the key priorities of the Healthy Families and 
Communities Subcommittee has been looking at how we can help 
students stay safe and protected in school.
    But in this subcommittee's first hearing, we are looking at 
what happens on the athletic field where many school injuries 
do occur.
    When a student suffers a concussion, a serious chain 
reaction can occur both on the field and in the classroom.
    On the playing field, concussions impose significant health 
risks to the students.
    While few states have laws, regulations or guidelines 
around concussions in high school athletics, the issue is 
gaining traction.
    In fact, there is a bipartisan bill currently pending in 
the New York legislature supported by both Republican Senator 
Hannon from Garden City and Democratic Senator Johnson of Port 
Washington.
    Recently, Suffolk County also passed a resolution on this 
important issue.
    High school athletes are at greater risk of sports-related 
concussions than college or professional athletes because their 
younger brains are more susceptible to injury.
    While we do not have Nassau or Suffolk County data, the New 
York State Department of Health reports that between 2006 and 
2008, more than 23,000 school-aged youths in our state visited 
the emergency room department for hospitalized concussions with 
the cost of their medical care approaching $480 million.
    Nationally, in the last three school years, 400,000 
concussions were reported in high school athletes.
    And, according to a recent Government Accountability 
report, this could be a low estimate.
    Studies show that the prevalence of sport-related 
concussions is much higher than has been reported.
    In fact, a recent study by the doctors at the Veterans 
Affairs Medical Center in Bedford, Massachusetts and the Boston 
University School of Medicine found that New York Yankee's 
famous slugger Lou Gehrig might not have had Lou Gehrig's 
disease.
    These findings confirm a long-suspected connection between 
motor disease such as Lou Gehrig's and head trauma experienced 
in collision sports and in combat.
    A concussion, unlike a sprain or a broken bone, is not 
easily detected.
    90 percent of concussions occur without the loss of 
consciousness.
    Concussions can cause a range of symptoms from altered 
mental status to physical symptoms such as headaches or 
dizziness to emotional changes like irritability and 
difficulties sleeping.
    The number and type of symptoms vary widely with each 
person.
    But unless a student takes time off from the field after 
suffering a concussion, he or she may be prolonging their 
recovery, and their success in school may suffer.
    Unfortunately, we also know that the symptoms of 
concussions are not only difficult to detect, but they are not 
always taken seriously.
    I have had too many parents in my lifetime say to me, ``
    It's only a concussion.'' That couldn't be further from the 
truth.
    In the sports injury community, there is a saying ``When in 
doubt, sit it out.''
    But a recent study shows that many students return to play 
much too soon.
    This is a problem that isn't limited to student athletes. 
College and professional athletes also feel pressure to compete 
and stay in the game.
    What we see here is that pressure to play is overriding 
medical concerns, and potentially increasing a risk of 
student's academic failure.
    As we will learn more about today, failing to sit it out 
after a concussion can negatively affect students in the 
classroom, sometimes causing symptoms to become worse when 
trying to focus on their schoolwork.
    Any parent can tell you that participating in sports 
doesn't just get the kids moving; it gives them skills that 
will come in handy in school, on the job and throughout their 
lives.
    During my school years I played field hockey, basketball 
and volleyball, and those experiences gave me a sense of 
confidence and teamwork, both of which are very, very 
important.
    You have to remember, I went to school a long time ago, and 
to be very honest with you, having young women practice or play 
in sports was not the top-rated agenda item of our schools. 
That has changed today, and in my view, it has changed for the 
better.
    Our goal today is to make sure that our kids can continue 
to participate in sports safely and continue to reap the 
benefits of athletic involvement both on and off the playing 
field.
    Early intervention and response, through the proper 
evaluation and management of concussions, will lessen the 
effects of this potentially life-threatening injury.
    I look forward to hearing from our witnesses today about 
what schools could be doing better to help support high school 
athletes, as well as the testimony on the effects of 
concussions on student achievement.
    Awareness and education hold the key to any solution.
    As the Committee continues our work on reorganizing the 
Elementary and Secondary Education Act, we must give serious 
consideration to the testimony before us today and determine 
how Congress can best move forward to prevent and treat 
concussions in our students.
    I want to thank you all for being here, and I look forward 
to your testimony.
    Right now I would like to introduce my colleague who also 
sits with me on the Education and Labor Committee, Tim Bishop, 
who represents this area.
    Tim?
    [The statement of Mrs. McCarthy follows:]

 Prepared Statement of Hon. Carolyn McCarthy, Chairwoman, Subcommittee 
                  on Healthy Families and Communities

    I'd like to welcome our witnesses to this hearing on student 
concussion safety.
    As a nurse for over 30 years, I have seen firsthand the damage that 
can occur as a result of concussions in our young people.
    Today we'll examine how concussions, experienced by high school 
athletes on the playing field, are impacting their academic well being 
and quality of life.
    We'll also learn more about how schools and the medical community 
can provide appropriate management and support for these young student 
athletes.
    One of the key priorities of the Healthy Families and Communities 
Subcommittee has been looking at how we can keep students safe and 
protected in school.
    But this is the subcommittee's first hearing looking at what 
happens on the athletic field, where many school injuries occur.
    When a student suffers a concussion, a serious chain reaction can 
occur both on the field and in the classroom.
    On the playing field, concussions can pose significant health risks 
to students.
    While few states have laws, regulations or guidelines around 
concussions in high school athletics, the issue is gaining traction.
    In fact there is a bipartisan bill currently pending in the New 
York legislature, supported by both Republican Senator Hannon from 
Garden City, and Democratic Senator Johnson of Port Washington.
    Recently, Suffolk County also passed a resolution on this important 
issue.
    High school athletes are at greater risk of sports-related 
concussions than college or professional athletes because their younger 
brains are more susceptible to injury. While we do not have Nassau or 
Suffolk County data, the New York State Department of Health reports 
that between 2006 and 2008 more than 23,000 school aged youths in our 
state visited the emergency department or were hospitalized for 
concussions annually with the cost of their medical care approaching 
four hundred and eighty million dollars.
    Nationally, in the last three school years, 400,000 concussions 
were reported in high school athletes. And according to a recent 
Government Accountability Office report, this could be a low estimate.
    Studies show that the prevalence of sport-related concussions is 
much higher than reported. In fact, a recent study from doctors at the 
Veterans Affairs Medical Center in Bedford, Massachusetts and the 
Boston University School of Medicine, found that New York Yankee's 
famous slugger Lou Gehrig might not have had Lou Gehrig's disease. 
These findings confirm a long-suspected connection between motor 
disease such as Lou Gehrig's and head trauma experienced in collision 
sports and combat. A concussion, unlike a sprain or a broken bone, is 
not always easily detected. Ninety percent of concussions occur without 
loss of consciousness. Concussions can cause a range of symptoms, from 
altered mental status to physical symptoms such as headaches or 
dizziness to emotional changes like irritability and difficulty 
sleeping. The number and type of symptoms vary widely for each person. 
But unless a student takes time off the field after suffering a 
concussion, he or she may be prolonging their recovery and their 
success in school may suffer.
    Unfortunately, we also know that the symptoms of concussions are 
not only difficult to detect, but are not always taken seriously. Many 
times we hear ``oh, it's just a concussion.''
    In the sports injury community, there is a saying: ``When in doubt, 
sit it out.'' But a recent study shows that many students return to 
play too soon. This is a problem that isn't limited to student 
athletes. College and professional athletes also feel the pressure to 
compete and stay in the game. What we see here is pressure to play is 
overriding medical concerns and--potentially--a student's academic 
future. As we will learn more about today, failing to ``sit it out'' 
after a concussion can negatively affect students in the classroom 
sometimes causing symptoms to become worse when trying to focus on 
schoolwork. Any parent can tell you that participating in sports 
doesn't just get their kids moving--it gives them skills that will come 
in handy in school, on the job and throughout their lives.
    During my school years I played field hockey, basketball, and 
volleyball and those experiences gave me a sense of confidence and 
teamwork which is so important. Our goal today is to make sure that our 
kids can continue to participate in sports safely--and continue to reap 
the benefits both on and off the playing field.
    Early intervention and response, by the proper evaluation and 
management of concussion will lessen the effects of this potential life 
threatening injury I look forward to hearing from our witnesses today 
about what schools can be doing better to help support high school 
athletes, and testimony on the effects of concussions on student 
achievement.
    Awareness and education hold the key to any solution. As the 
Committee continues our work on reauthorizing the Elementary and 
Secondary Education Act, we must give serious consideration to the 
testimony before us today and determine how Congress can best move 
forward to prevent and treat concussion in our students.
    Thank you all for being here and I look forward to your testimony.
                                 ______
                                 
    Mr. Bishop. Thank you very much.
    I will start by thanking my friend, Chairwoman McCarthy, 
for holding this field hearing here in the First Congressional 
District of New York, and to all of you welcome to the First 
Congressional District of New York.
    Let me also thank our witnesses, for each of them being 
here today to share their thoughts and experiences about this 
important issue.
    As an avid sports fan, a father of two high school athletes 
and as an athlete myself, this is an issue of great concern to 
me.
    Concussions occur when there is a severe blow or motion to 
the head that causes the brain to move rapidly.
    Many are well aware that professional athletes suffer 
concussions and that the consequences of these concussions can 
be severe, but what most do not know is that concussions are 
even more prevalent for high school athletes.
    Student athletes are even more susceptible to head injuries 
than professionals because their brains are still developing. 
Unfortunately, unlike other types of injuries, concussions are 
not visible and often go unnoticed.
    When concussions are undiagnosed, they can affect a 
student's performance both on and off the field, as we will 
hear from one of our witnesses.
    In many ways, concussions are more severe than other 
injuries causing lingering physical and emotional pain.
    Students who suffer concussions often have physical side 
symptoms like headaches, but later report having difficulty 
concentrating and trouble sleeping, often affecting their 
academic performance.
    A recent Government Accountability Office report found that 
concussions are severely under-reported by schools, and we have 
no real way of telling just how many occur each year.
    Last year the Suffolk County Legislature passed a 
resolution to approve the safety in youth sports and increase 
the awareness of the dangers of head injuries.
    The resolution requires Suffolk County-contracted youth 
sports agencies to provide parents with information on youth 
sports and concussions.
    The resolution also aims to prevent children suspected of 
suffering from concussions to resume play until they are 
medically cleared. Oftentimes, coaches do not know that the 
athlete is suffering from a concussion, and the athlete 
continues to play, causing further damage.
    In addition, the resolution requires youth sports agencies 
to develop a plan to address possible or actual head injuries.
    While I applaud Suffolk County for addressing the issue of 
head injuries and think this will be helpful in raising 
awareness, more must done.
    Currently, there is no Federal law to protect or educate 
students and their parents about the dangers and warning signs 
of concussions.
    At a time when we are encouraging all students to become 
more active and participate in organized sports, we must also 
take the steps necessary to ensure their safety.
    As Congress continues to work on reauthorizing the 
Elementary and Secondary Education Act, I hope that we can take 
the recommendation of our witnesses into consideration and 
determine how best Congress can address this issue.
    Thank you, again, all for being here, and I look forward to 
hearing your testimony.
    Chairwoman McCarthy. Thank you, Mr. Bishop.
    Pursuant to Committee Rule 12(a), any member may submit an 
opening statement in writing at this time which will be made 
part of the permanent record.
    Without objection, all members will have 14 days to submit 
additional materials or questions for the hearing record.''
    First of all, I would like to briefly introduce our 
distinguished panel of witnesses with us here today. The 
complete bios of the witnesses will be inserted into the 
record.
    Mr. Bishop, will you introduce the first two witnesses?
    Mr. Bishop. We have a very distinguished panel this 
afternoon of five.
    It is my honor to introduce our first two witnesses. The 
first is Dr. Hayley Queller.
    Dr. Queller is a primary care sports medicine physician for 
Orthopedic Associates of Long Island, LLC in East Setauket, New 
York.
    Dr. Queller has a dual board certification both in internal 
medicine and pediatrics from Christiana Health System in 
Delaware.
    After completing her primary care training, she continued 
her training by completing a fellowship in primary care sports 
medicine.
    Through her training, she had a particular interest in 
concussion management. She recognized the importance of 
appropriate education, recognition and treatment of sports-
related concussions. Dr. Queller recognized a lack of 
comprehensive concussion programs in the area when she moved to 
Suffolk County, and she was determined to initiate a concussion 
management program targeting high school athletes.
    In 2010 she, along with her colleagues at Orthopedic 
Associates of Long Island, started such a program in many of 
the local high schools. This program includes baseline 
neurocognitive testing, post concussion evaluation/treatment 
and return to play decision making. The goal is to increase the 
awareness of concussion management and to make return to play 
as quick and as safe as possible for the athletes in the 
community.
    Welcome.
    Dr. Queller. Thank you.
    Mr. Bishop. Our second witness will be Craig LoNigro.
    Craig is a certified athletic trainer and holds a bachelors 
of science degree from Hofstra University in exercise 
physiology with a minor in athletic training, and a masters 
degree with distinction from Hofstra University in education 
specializing in physical education and health.
    Mr. LoNigro is a physical education and health teacher and 
certified athletic trainer at Comsewogue High School here in 
Suffolk County.
    He serves as the director and founder of the Suffolk County 
High School Athletic Trainers Association as well as being a 
member of the Suffolk County Section 11 Safety Committee.
    He has served as a certified athletic trainer on almost 
every level of competition from NCA Division 1, 2 and 3, 
professional Lacrosse and soccer, and as an intern with the New 
York Jets football club.
    He has worked at the international level as the head 
athletic trainer for the US men's Lacrosse team, who captured 
the world championship in 2003.
    Mr. LoNigro also provides services to many charitable 
organizations like the Boomer Esiason Foundation for Cystic 
Fibrosis and the Suffolk County Police Athletic League.
    Mr. LoNigro has taken a sincere interest in the area of 
cervical spine injuries and concussion management in athletics 
and presents educational information and seminars on these 
topics to the youth leaders of Long Island.
    Mr. LoNigro has also been coordinating medical coverage in 
athletic training services in many of the large competitive 
athletic events and tournaments from all over the tristate area 
for the last 20 years in an effort to keep the fields of Long 
Island a safer place.
    Thank you for being here.
    Mr. LoNigro. Thank you.
    Chairwoman McCarthy. Thank you, Mr. Bishop.
    Our next witness is Caitlin Monaghan.
    Caitlin is a graduate of Garden City High School and 
recently of Georgetown University. She was a varsity soccer 
player during high school and will share her story about her 
experience with concussions and their aftermath.
    Mr. Caster is a former wide receiver and tight end, playing 
13 seasons in the league. He has been a strong advocate on this 
issue and has worked locally with groups such as the Head 
Injury Association of Long Island.
    Our final witness is Mr. Courtney Hall.
    Mr. Hall is a co-founder and managing director of Hillcrest 
Venture Partners, a venture capital firm.
    He was the starting center for the NFL San Diego Chargers 
where he was a captain, four-time Pro Bowl 1st Alternate, and 
he captained the Chargers to the 1994-95 Super Bowl.
    He also founded EXACT Sports, a company that performs 
assessments of the athletic, psychological and neurocognitive 
abilities of high school and collegiate athletes.
    Welcome to all of our witnesses. I really, really 
appreciate you taking the time out to be here.
    For those of you who have not testified before Congress 
before, let me explain the lighting system. We have five 
minutes, five minutes for the witness, five minutes for the 
members of Congress.
    The green light when you first start speaking will go on. 
Then it will turn yellow. You have one minute to finish up. 
Then you have red, which means we ask you to finish up your 
thought.
    Being that it is just Mr. Bishop and I, I have been known 
to be lax at times on allowing the witness to expand. That is 
what we are here for, and if there is no time constraints on 
your side or with Mr. Bishop, that is the way I will run this 
particular hearing.
    Please make sure when you are speaking, make sure the 
microphone is on, and make sure it is close to you so not only 
are you speaking to us, but you are speaking to the people 
behind us.
    We now will hear from our first witness.
    Dr. Queller?

  STATEMENT OF HAYLEY QUELLER, M.D., ORTHOPEDIC ASSOCIATES OF 
                          LONG ISLAND

    Dr. Queller. Good morning, Mrs. Chairwoman, Mr. Bishop, 
members of the committee and fellow speakers.
    I want to thank you for inviting me to speak to you today 
about concussion management in the high school athlete. Like 
the other witnesses testifying today, I have a strong interest 
in improving concussion awareness and management in the local 
community.
    I am honored to have the opportunity to discuss this 
important topic with you today, and I look forward to being 
part of the process as the Committee improves the safety of our 
high school athletes.
    Reinforcing what Dr. Gioia had testified about in previous 
testimony in May down in Washington, DC, a concussion is a 
functional rather than a structural disturbance of the brain 
after a direct or indirect blow to the head. The developing 
brain of adolescents is much more susceptible to this metabolic 
disturbance when compared to adults.
    From a clinical standpoint a concussion may present with 
physical, emotional or cognitive disturbance.
    Unfortunately, these injuries are notoriously missed and 
highly under-reported.
    Early recognition of this injury is paramount to the 
appropriate treatment and safety of the high school athlete.
    Without appropriate diagnosis, student athletes are at risk 
of significant untoward effects, including the fatal second 
impact syndrome, as well as other psychological, emotional and 
cognitive deficits in the future.
    There is data to support, however, that once the student 
athlete has fully recovered from a concussion, the concussed 
athlete will have no permanent sequelae.
    The fact that we are all gathered here today proves to me 
that we are all in agreement that it is essential to establish 
a gold standard for the management of concussion in the high 
school athlete.
    My colleagues at Orthopedic Associates of Long Island and I 
have drafted a concussion management protocol that we feel is 
comprehensive and safe for our high school athletes. The 
program includes community-wide education, baseline 
neurocognitive testing, prompt recognition, conservative 
treatment, and a safe return to play of the concussed athlete.
    We feel that the most important aspect of the concussion 
management protocol is the education of our community. This 
education must include the recognition of signs and symptoms, 
the importance of treatment, as well as understanding the 
potential long term sequelae should the injury be 
inappropriately treated.
    Getting out of the warrior mentality of the past is 
essential. Instead of being encouraged to hide their symptoms, 
athletes should feel comfortable and be encouraged to report 
their symptoms.
    Initially, this education goal can be achieved by using 
prepared materials from the CDC including Heads Up Concussion 
in High School Sports and Know Your Concussion ABCs.
    My colleagues and I have lectured at local high schools and 
at hospitals with excellent response.
    We would like to specifically target local physicians, as 
these are the practitioners that are sought to treat these 
patients to make return to play decisions. The local physicians 
must all be on the same page when it comes to concussion 
management so as to have consistency in treatment and safe 
return to play.
    There are vast educational opportunities for these 
practitioners to learn the most up-to-date information on 
concussion management.
    As a next step, we have been involved in baseline 
neurocognitive testing of high school athletes in four local 
high schools. Over the recent years, this testing has become an 
objective tool that can be used to identify a concussion, 
monitor improvement, and help student athletes get back onto 
the field in a safe manner.
    My goal is to have baseline testing for all contact and 
collision sports for the high schools in Suffolk County.
    Until baseline testing is available for all athletes, 
however, normative data can be used to help in returning these 
athletes to play.
    Another key component of concussion management is the 
proper initial treatment of the head injury. At the high school 
level, if there is any suspicion at all of a head injury, the 
student should be removed immediately from play. When in doubt, 
sit them out. The student athlete should be kept out of play 
and should not be allowed to return until evaluated by medical 
personnel knowledgeable in the treatment of concussions.
    The clearance should come from somebody who has continuing 
education in concussion management.
    It is important to recognize that the athlete should then 
be reevaluated within the first 48 to 72 hours after the injury 
as symptoms often develop in this initial post-concussive 
period.
    Once diagnosed with a concussion, the treatment should 
include physical and cognitive rest. I think we can all agree 
that a student athlete should be restricted from physical 
exertion until they are symptom free.
    Additionally, these students should be restricted from any 
cognitive activity that may exacerbate their symptoms. This may 
include keeping the student out of school until their symptoms 
resolve.
    As for physical exertion, students should be brought 
through a five-step return to activity protocol including light 
aerobic activity, followed by sports specific exercise, non-
contact drills, full contact practice and, finally, full 
competition, assuming their symptoms do not return.
    Until the student athlete is symptom free at rest, symptom 
free with both physical and cognitive exertion and have a 
normal neurocognitive examination, I do not allow these 
students to return to play.
    In collision sports and in those athletes who have had 
prolonged symptoms or recurrent concussions, performing 
neurocognitive testing after physical exertion to ensure that 
their symptoms do not return may be beneficial.
    In summary, it is absolutely essential that there be a 
comprehensive concussion management program established in all 
high schools, as well as in all youth sports.
    Without such a program, we are putting our youth at risk of 
experiencing long-lasting emotional, physical and academic 
deficits.
    To ensure that such programs are created, the first step 
must be community-wide education.
    Injury prevention, early identification and appropriate 
management are the principal components to ensure the safe 
return of our high school athletes back to their sports 
activities.
    Thank you very much for allowing me to speak on this 
extremely important topic.
    Chairwoman McCarthy. Thank you very much.
    [The statement of Dr. Queller follows:]

         Prepared Statement of Hayley C. Rintel Queller, M.D.,
   Primary Care Sports Medicine, Orthopedic Associates of Long Island

Biography
    Dr. Hayley C. Rintel Queller is a Primary Care Sports Medicine 
physician for Orthopedic Associates of Long Island, LLC in East 
Setauket, NY. Dr. Queller has a dual board certification in both 
Internal Medicine and Pediatrics from Christiana Care Health System in 
Delaware. After completing her primary care training, she continued her 
training by completing a fellowship in Primary Care Sports Medicine. 
Through her training, she had a particular interest in concussion 
management. She recognized the importance of appropriate education, 
recognition and treatment of sports related concussions. Dr. Queller 
recognized a lack of a comprehensive concussion program in the area 
when she moved to Suffolk County and was determined to initiate a 
concussion management program targeting high school athletes. In 2010, 
she, along with her colleagues at Orthopedic Associates of Long Island, 
LLC, started such a program in many of the local high schools. This 
program includes baseline neurocognitive testing, post concussion 
evaluation/treatment and return to play decision making. The goal is to 
increase the awareness of concussion management and to make return to 
play as quickly and as safe as possible for the athletes in the 
community.

Testimony
    Good morning Mr. Chairman, members of the committee and fellow 
speakers. I want to thank you for inviting me to speak to you today 
about concussion management in the high school athlete. Like the other 
witnesses testifying today, I have a strong interest in improving 
concussion awareness and management in the local community. I am 
honored to have the opportunity to discuss this important issue with 
you today and look forward to being part of the process as the 
committee improves the safety of the high school athletes in our area.
    Reinforcing what Dr. Gioia stated in previous testimony, a 
concussion is a functional rather than structural disturbance of the 
brain after a direct or indirect blow to the head. The developing brain 
of adolescents is more susceptible to this metabolic disturbance when 
compared to adults. From a clinical standpoint, a concussion may 
present with physical, emotional or cognitive disturbance. 
Unfortunately, these injuries are notoriously missed and under-
reported. Early recognition of this injury is paramount to the 
appropriate treatment and safety of the high school athlete. Without 
appropriate diagnosis, student-athletes are at risk of significant 
untoward effects including the fatal ``second impact syndrome,'' as 
well as, other psychological, emotional and cognitive deficits in the 
future. There is data to support, however, that once the student-
athlete has fully recovered from a concussion, that the concussed 
patient will have no permanent sequelae.
    The fact that we are all gathered here today proves to me that we 
are all in agreement that it is essential to establish a gold standard 
for the management of concussions in the high school athlete. My 
colleagues at Orthopedic Associates of Long Island, LLC and I have 
drafted a concussion management protocol that we feel is comprehensive 
and safe for our high school athletes. This program includes community-
wide education, baseline neurocognitive testing, prompt recognition, 
conservative treatment, and safe return to play of the concussed 
athlete.
    We feel that the most important aspect of concussion management is 
in the education of the community (athletes, parents, coaches, school 
nurses, referees, teachers, etc). This education must include the 
recognition of signs and symptoms of concussion, as well as, the 
importance of treatment and the potential long-term sequelae should the 
injury be inappropriately treated. Getting out of the ``warrior'' 
mentality of the past is essential. Instead of being encouraged to hide 
their symptoms, athletes should feel comfortable and encouraged to 
report their symptoms. Initially, this goal can be achieved using 
prepared materials by the CDC (``Heads Up Concussion in High School 
Sports'' and ``Know Your Concussion ABCs''). My colleagues and I have 
lectured at local high schools and hospitals with excellent response. 
We would specifically like to target local physicians as these are the 
practitioners that are sought to treat these patients and make return 
to play decisions. The local physicians must all be on the same page 
when it comes to concussion management so as to have consistency in 
treatment and safe return to play. There are vast educational 
opportunities for these practitioners to learn the most up to date 
information on concussion management.
    As a next step, we have been involved in baseline computerized 
neurocognitive testing of athletes in 4 high schools. Over recent 
years, this testing has become an objective tool that can be used to 
identify a concussion, monitor improvement and help get student-
athletes back onto the field in a safe manner. My goal is to have 
baseline testing for all contact and collision sports for the high 
schools in Suffolk County. Until baseline testing is available for all 
athletes, however, normative data can be used to help in return to play 
decisions.
    Another key component of concussion management is proper initial 
treatment of the head injury. At the high school level, if there is any 
suspicion of a head injury, the student athlete should be removed from 
play; WHEN IN DOUBT, SIT THEM OUT. The student-athlete should be kept 
out of play and should not be allowed to return until evaluated by 
medical personnel knowledgeable in the management of concussions. This 
``clearance'' should come from a medical professional who has 
continuing education in concussion management. It is important to 
recognize that the athlete should be re-evaluated 48-72 hours after 
their injury as symptoms often develop in the initial post-concussive 
days.
    Once diagnosed with a concussion, the treatment should include 
physical and cognitive rest. I think we can agree that the student-
athlete should be restricted from any physical exertion until they are 
symptom-free. Additionally, these student-athletes should be restricted 
from any cognitive activities that may exacerbate their symptoms. This 
may include keeping the student-athlete out of school according to 
their symptoms. As for physical exertion, they are brought through a 5 
step return to activity starting with light aerobic activity, followed 
by sports-specific exercise, non-contact drills, full contact practice 
and finally, full competition. Until the student athlete is 1) symptom-
free at rest, 2) symptom-free with exertion (both physical and 
cognitive) and 3) have a ``normal'' neurocognitive examination, we do 
not allow these athletes to return to play. In collision sports and in 
those athletes that have prolonged symptoms, performing neurocognitive 
testing after physical exertion to ensure deficits do not return with 
activity may be beneficial.
    In summary, it is absolutely essential that there be a 
comprehensive concussion program established in all high schools, as 
well as, all youth sports. Without such a program, we are putting our 
youth at risk of experiencing long-lasting emotional, psychological and 
academic deficits. To ensure that such programs are created, the first 
step is community-wide education. Injury prevention, early 
identification and appropriate management are the principal components 
to ensure the safe return of our high school athletes back to their 
sports activities. Thank you for your support on this extremely 
important topic.
                                 ______
                                 
    Chairwoman McCarthy. Next we are going to hear from Mr. 
Craig LoNigro.

    STATEMENT OF CRAIG LO NIGRO, ATHLETIC TRAINER, PHYSICAL 
      EDUCATION AND HEALTH TEACHER, COMSEWOGUE HIGH SCHOOL

    Mr. LoNigro. Thank you.
    Chairwoman McCarthy, Congressman Bishop and other 
distinguished guests, my name is Craig LoNigro. I am a 
Certified Athletic Trainer, Physical Education and Health 
teacher at Comsewogue High School here in Suffolk County.
    As a father of two athletes and an athlete myself, as well 
as a health care professional, I am passionate about safety in 
youth sports.
    Thank you for allowing me the opportunity to speak on 
behalf of the National Athletic Trainers Association, the 
Suffolk County High School Athletic Trainers Association, today 
about the athletic trainer's role in concussions and concussion 
management.
    As you may know, athletic trainers are health care 
professionals who collaborate with physicians to optimize 
activity of participation and participation of patients.
    Athletic training encompasses the prevention, diagnosis and 
intervention of emergency, acute and chronic medical conditions 
leading to impairment, functional limitations and disabilities.
    All athletic trainers have at least a bachelor's degree in 
athletic training from an accredited college or university, and 
70 percent of our membership has a master's degree or higher.
    Certified athletic trainers must pass a national 
certification, and in most of the 47 states where they are 
licensed or otherwise regulated, the national certification is 
required for licensure.
    Athletic trainers maintain this certification with required 
continuing medical education. We work under the medical scope 
of practice and under the direction of physicians and adhere to 
a national code of ethics.
    Although this issue of concussions in sports has received a 
great deal of attention in the media of recent months, it is 
not a new problem. Athletic trainers have been caring for 
concussed athletes and warning of the dangers posed to them by 
this unique injury for years.
    The NATA represents over 35,000 certified and student 
athletic trainers. As athletic trainers and health care 
professionals specializing in team sports, we are the first 
line of defense in the prevention, diagnosis and emergency 
treatment of head trauma and other athletic-related injury.
    While much focus has been given to players in the NFL, the 
National Football League, it is important to remember that high 
school athletes represent the single largest segment of 
football players in the country and account for the majority of 
sports-related concussions. In a given year, between 4 and 6 
percent of high school athletes sustain concussions 
corresponding to an estimated 43 to 67,000 injuries annually.
    In fact, there are five times as many catastrophic football 
injuries among high school athletes as per college athletes.
    Estimates indicate, however, the true incidence of injury 
is much, much higher. Some research suggests that more than 
half of the high school athletes who suffer concussions do not 
report their injuries to medical personnel.
    Even when faced with these disturbing trends and the fact 
that 7 million students participate in high school sports in 
the United States, the NATA estimates that only about 42 
percent of the public high schools in American have access to 
an athletic trainer. In fact, the NATA also estimates that 
across the country, the ratio of students to athletic trainers 
is 2,678 to 1.
    Furthermore, some studies have also shown that 50 percent 
of second impact syndrome incidents, as Dr. Queller had 
mentioned, result in death.
    Other startling statistics may include female high school 
soccer athletes suffer almost 40 percent more concussions than 
males, 29,000 annually.
    Female high school basketball athletes suffer 240 percent 
more concussions than males, 13,000 annually.
    It is not just a condition related to football; it is with 
all sports.
    Concussion symptoms such as headache and disorientation may 
disappear within 15 minutes, but 75 percent of those tested 36 
hours later still had problems with memory and cognition.
    I have been a certified athletic trainer for just over 20 
years and have been fortunate to have had the opportunity to be 
involved in athletics on every level.
    As an athletic trainer, it is my obligation to pay 
attention to every play of every game so that I may be able to 
see the injury happen, the injury occur, know the severity and 
know the mechanism.
    I have personally witnessed an athlete sustain a head 
injury in a big game against a rival team. While the athlete 
and the coaches, for that matter, wants this player to return 
to the field, it is my job to make the assessment about what is 
best for the athlete and the health of the player.
    As an athletic trainer, one of my more difficult 
responsibilities of my job is to tell an athlete that they 
cannot play in a game that they have worked so hard to prepare 
for.
    It is my job as well to educate the athlete and the 
coaching staff to realize the severity of the issues in hopes 
of preventing more serious or fatal repercussions.
    It is my job to convince the athlete, his or her parents 
and the coaching staff, that if action is not taken swiftly, we 
could be dealing with a much bigger issue than losing a game. 
Sometimes this process is simple, and sometimes it is as big a 
battle as the game itself.
    The NATA has developed some recommendations on addressing 
head injuries in football. Those recommendations include using 
the Graded Symptom Checklist, which is distributed within the 
NATA's position statement Management of Sports-Related 
Concussion. This treatment tool can help determine whether a 
concussion has occurred, the severity of the injury, and 
whether a player is fit to return to play.
    Athletic trainers or physicians who suspect that an athlete 
has suffered a concussion can use this checklist to evaluate a 
player both at rest and during physical exertion.
    In response to the national youth sports safety crisis in 
America, the NATA has spearheaded the Youth Sports Safety 
Alliance, an initiative to raise awareness, advance legislation 
and improve medical care for young athletes.
    This call to action includes: Ensuring that the youth 
athletes have access to health care professionals who are 
qualified to make assessments and return to play decisions, 
ensuring pre-participation physicals before play begins, and 
recognizing the difference in pain and injury and working 
towards the elimination of the culture of playing through pain 
without any type of assessment.
    In consultation with the NATA Secondary School Athletic 
Trainers Committee, the NATA Government Affairs Committee and 
the NATA Federal Legislative Council, the NATA has developed a 
set of principles surrounding the issue of concussion 
management and possible future legislation.
    The NATA's principles include the following: One, 
increasing student athletes access to certified athletic 
trainers is the first step in helping to prevent concussion and 
manage concussions once they occur. Legislation should 
incentivize schools and school districts to increase the 
accessibility of an athletic trainer to their student athletes.
    Number two, conduct baseline testing of student athletes 
prior to engagement in contact sports, which will provide the 
greatest opportunity to ensure accurate assessment of a 
player's condition after sustaining a concussion.
    Educating parents, coaches, teachers and other stakeholders 
about the signs and symptoms of concussions is critically 
important.
    Programs such as the CDCs Heads Up program are important 
tools, and at the same time, concussion education and awareness 
programs should not provide a false sense of comfort that non-
medical professionals are able to diagnose and treat 
concussions. Rather, the focus should be to educate the 
stakeholders about making the proper referral in the event that 
the signs and symptoms of a concussion are present in a 
student.
    State task forces that may be established to develop and 
implement state plans for concussion management should 
hopefully include representatives of the state's athletic 
training association, the state's athletic association, medical 
society and the Department of Ed.
    Athletic trainers serve as the lynchpin medical 
professional who seeks input from all members of the concussion 
management team regarding the return to play decision.
    The athletic trainer's standard practice is to ensure 
involvement of a team comprised of the student athlete, family/
parent, the treating physician and school personnel such as the 
coach, school nurse and teachers in their approach to 
concussion management with respect to the decision about return 
to play.
    The athletic trainer is responsible for coordinating the 
school's emergency action plan, concussion testing programs, 
medical coverage and more. In the absence of an athletic 
trainer, these responsibilities often fall to an unqualified 
non-medical personnel.
    Currently the New York State legislature is considering 
several bills of important. First is SB 6297, which would 
provide athletic training and institute regulations for 
management of head injuries.
    We are very appreciative that the legislature has 
collaborated with the New York State Athletic Training 
Association on this bill.
    Recently as well, AB 10890 was introduced. This bill would 
require the Commissioner of Education to establish minimum 
standards for training coaches and set qualifications of health 
care providers for making return to play decisions.
    The NATA has also endorsed Representative Bill Pascrell's 
Concussion Treatment and Care Tools ConTACT Act, of which 
Chairwoman McCarthy is a co-sponsor.
    The NATA applauds the creation of national guidelines to 
address the prevention, identification, treatment and 
management of concussions in school-age children, including 
return to play decisions, which are included in the bill.
    I greatly appreciate the opportunity to participate in this 
hearing and offer the National Athletic Trainers Association as 
well as the Suffolk County High School Athletic Trainers 
Association as a resource to you and other members of the 
subcommittee as we work and move forward to address this 
important issue facing the youth of our nation.
    Thank you.
    Chairwoman McCarthy. Thank you.
    [The statement of Mr. LoNigro follows:]

   Prepared Statement of Craig LoNigro, M.S., ATC, Athletic Trainer, 
                         Comsewogue High School

    Chairwoman McCarthy, Congressman Bishop and other distinguished 
guests, my name is Craig LoNigro. I am a Certified Athletic Trainer, 
Physical Education and Health teacher at Comsewogue High School here in 
Suffolk County, New York. As a father and health care professional, I 
am passionate about safety in youth sports.
    Thank you for allowing me the opportunity to speak on behalf of the 
National Athletic Trainers' Association (NATA) today about the athletic 
trainer's role in concussion management.
    As you may know, ATs are health care professionals who collaborate 
with physicians to optimize activity and participation of patients. 
Athletic training encompasses the prevention, diagnosis, and 
intervention of emergency, acute and chronic medical conditions leading 
to impairment, functional limitations and disabilities.
    All ATs have at least a bachelor's degree in Athletic Training from 
an accredited college or university, and 70% of our membership has a 
master's degree or higher. Certified ATs must pass a national 
certification exam. In most of the 47 states where they are licensed or 
otherwise regulated, the national certification is required for 
licensure. ATs maintain this certification with required continuing 
medical education. They work under a medical scope of practice and 
under the direction of physicians and adhere to a national code of 
ethics.
    Although the issue of concussions in sports has received a great 
deal of attention in the media in recent months, it is not a new 
problem. Athletic trainers have been caring for concussed athletes and 
warning of the dangers posed by this unique injury for years.
    The NATA represents over 35,000 athletic trainers (ATs). As 
athletic trainers and health care professionals specializing in team 
sports, we are the first line of defense in the prevention, diagnosis 
and emergency treatment of head traumas and other athletic injuries.
    NATA has a long history of working with research experts to explore 
the prevention and proper treatment of head injuries. In July 2009, 
NATA released a study in the Journal of Athletic Training entitled Head 
Impacts During High School Football: A Biomechanical Assessment. The 
study revealed that high school football players sustain greater head 
accelerations after impact than do college-level football players, 
which can lead to concussions and serious cervical spine injuries. 
Further, the study urged high school coaches to teach proper tackling 
techniques in order to reduce the risk of head and neck injuries among 
athletes.
    While much focus has been given to players in the National Football 
League (NFL), it is important to remember that high school athletes 
represent the single largest segment of football players in the country 
and account for the majority of sport-related concussions. In a given 
year, between four and six percent of high school football athletes 
sustain concussions, corresponding to an estimated 43,200 to 67,200 
injuries annually. In fact, there are five times as many catastrophic 
football injuries among high school athletes as college athletes. 
Estimates indicate, however, the true incidence of injury is likely 
much higher. Some research suggests that more than half of high school 
athletes who suffer concussions do not report their injuries to medical 
personnel. Even when faced with these disturbing trends and the fact 
that 7 million students participate in high school sports in America, 
the NATA estimates that only 42 percent of public high schools in 
America have access to an athletic trainer. In fact, NATA estimates 
that across the country, the ratio of students to athletic trainers is 
2,678 to 1.
    According to a New York Times article (Sports Imperative: 
Protecting Young Brains, August 24, 2009), ``at least four American 
high school students died last year from football head injuries. Most 
suffered from what is called second-impact syndrome, a rare but 
catastrophic dysregulation of brain activity that can occur when a 
young player sustains another hit before the brain has recovered from 
an earlier concussion. In nearly all cases, such tragedies can be 
prevented if the symptoms of concussion are recognized and heeded, 
giving the injured brain time to fully heal.''
    Furthermore, studies also show that fifty percent of second impact 
syndrome incidents result in death. Other startling statistics include:
     Female high school soccer athletes suffer almost 40% more 
concussions than males (29,000 annually). Journal of Athletic Training, 
July--September 2003
     Female high school basketball athletes suffer 240% more 
concussions than males (13,000 annually). Journal of Athletic Training, 
July--September 2003
     400,000 brain injuries (concussions) occurred in high 
school athletics during the 2008-09 school year. Compliance with return 
to play guidelines following concussion in US high school athletes, 
2005-2008
     Concussion symptoms such as headache and disorientation 
may disappear in fifteen minutes, but 75% of those tested 36 hours 
later still had problems with memory and cognition. Journal of Athletic 
Training, July--September 2003
     15.8% of football players who sustain a concussion severe 
enough to cause loss of consciousness return to play the same day. 
Center for Injury Research and Policy, The Research Institute at 
Nationwide Children's Hospital, Dr. Dawn Comstock
Addressing the Issue Locally
    I have been a certified athletic trainer for just over 20 years. I 
have been fortunate to have had the opportunity to be involved in 
athletics at every level of competition, including youth league 
programs like the distinguished Suffolk County Police Athletic League 
(PAL), as well as high school and middle school programs. On the 
international level, I served as the Head Athletic Trainer for the USA 
World Championship Mens' Lacrosse team in 2003. On the professional 
level, I served as the head athletic trainer for both professional 
lacrosse and soccer here on Long Island. My college education from 
Hofstra University culminated in an internship with the New York Jets 
Football Club medical staff as a student athletic trainer.
    As an athletic trainer, it is my obligation to pay attention to 
every play of every game so that I may be able to see an injury happen 
and know the severity. I have personally witnessed an athlete sustain a 
head injury in a big game against the rival team. While the athlete 
(and the coaches for that matter) wants to return to the field, it is 
my job to make the assessment about what is best for the health of that 
player. As an athletic trainer, one of the more difficult 
responsibilities of my job is to tell an athlete that they cannot play 
in a game that they have worked so hard to prepare for.
    It is my job to educate the athlete and the coaching staff to 
realize the severity of issues, in hopes of preventing more serious or 
even fatal repercussions. It is my job to convince the athlete, his/her 
parents and the coaching staff that if action is not taken quickly, we 
could be dealing with a much bigger issue than losing a game. Sometimes 
this process is simple, and other times it is as big of a battle as the 
game itself.
NATA's Recommendation on Addressing Head Injuries in Football
    The NATA has developed recommendations on addressing head injuries 
in football. Those recommendations include using the ``Graded Symptom 
Checklist,'' which is distributed within NATA's position statement 
``Management of Sport-Related Concussion.'' This treatment tool can 
help determine whether a concussion has occurred, the severity of the 
injury and whether a player is fit to return to play. Athletic trainers 
or physicians who suspect that an athlete has suffered a concussion can 
use the checklist to evaluate a player both at rest and during physical 
exertion.
    In response to the national youth sports safety crisis in America, 
the NATA has spearheaded the Youth Sports Safety Alliance, an 
initiative to raise awareness, advance legislation, and improve medical 
care for young athletes. This call to action includes:
     Ensuring that youth athletes have access to health care 
professionals who are qualified to make assessments and return to play 
decisions;
     Ensuring pre-participation physicals before play begins; 
and
     Recognizing the difference in pain and injury and working 
toward the elimination of the culture of ``playing through pain'' 
without assessment.
NATA's Recommendations for Concussion Legislation
    In consultation with the NATA Secondary School Athletic Trainers' 
Committee, the NATA Government Affairs Committee and the NATA Federal 
Legislative Council, NATA has developed a set of principles surrounding 
the issue of concussion management and possible future legislation. 
NATA's principles include the following:
     Increasing student athletes' access to a certified 
athletic trainer is the first step in helping to prevent concussions 
and manage concussions once they occur. Legislation should incentivize 
schools and school districts to increase the accessibility of an 
athletic trainer to their student athletes.
     Conducting baseline testing of student athletes prior to 
engagement in contact sports provides the greatest opportunity to 
ensure accurate assessment of a player's condition after sustaining a 
concussion. Funding should be made available to schools and school 
districts to conduct appropriate baseline testing for symptoms, 
cognitive function and balance.
     Educating parents, coaches, teachers and other 
stakeholders about the signs and symptoms of concussions is critically 
important. Programs such as the Centers for Disease Control and 
Prevention's (CDC) ``Head's Up'' program are important tools. At the 
same time, concussion education and awareness programs should not 
provide a false sense of comfort that non-medical professionals are 
able to diagnose and treat concussions. Rather, a focus should be to 
educate stakeholders about making a proper referral if the signs and 
symptoms of a concussion are present in a student.
     State Task Forces that may be established to develop and 
implement state plans for concussion management should include 
representatives of the state's athletic training association, athletic 
association, medical society, and Department of Education.
     Athletic trainers serve as the lynchpin medical 
professional who seeks input from all members of the concussion 
management team regarding the return to play decision. Athletic 
trainers' standard practice is to ensure involvement of a team 
comprised of the student athlete, family/parent, treating physician and 
school personnel such as the coach, school nurse and teachers in their 
approach to concussion management with respect to a decision about 
return to play. The athletic trainer is responsible for coordinating 
the school's emergency action plan, concussion testing program, medical 
coverage and more. In the absence of an athletic trainer, these 
responsibilities often fall to unqualified, non-medical personnel.
     Although the best case scenario is for a school to have 
access to an athletic trainer on faculty or staff, in the absence of a 
licensed or certified athletic trainer, the treating physician should 
make return to play decisions in consultation with school personnel, 
the student athlete and his/her family.
Other State and Federal Legislative Initiatives Related to Head Injury
    Currently, the New York state legislature is considering several 
bills of importance. First is SB 6297, which would provide training and 
institute regulations for management of head injuries. We are very 
appreciative that the legislature has collaborated with the New York 
State Athletic Training Association on the bill language.
    Recently, AB 10890 was introduced. This bill would require the 
Commissioner of Education to establish minimum standards for training 
coaches and set the qualifications of health care providers for making 
return to play decisions.
    Finally, head injury awareness legislation, SB 8420 and AB 11605, 
has been introduced.
    The NATA has endorsed Representative Bill Pascrell's Concussion 
Treatment and Care Tools (ConTACT) Act (H.R. 1347) of which Chairwoman 
McCarthy is a co-sponsor. NATA applauds the creation of national 
guidelines to address the prevention, identification, treatment and 
management of concussions in school-aged children, including return to 
play decisions included in the bill.
    In addition to these items, the NATA strongly supports the 
recognition of athletic trainers as health care providers under the 
Medicare and Medicaid programs. This would encourage private insurance 
companies to reimburse athletic trainers for physical medicine and 
rehabilitation services they provide. This legislative action would 
assist in making more athletic trainers available in high schools and 
local medical facilities to treat those individuals suffering from head 
trauma or other sports related injuries where they occur.
Conclusion
    I greatly appreciate the opportunity to participate in this hearing 
and offer the National Athletic Trainers' Association as a resource to 
you and other members of the Subcommittee as you work to address this 
important issue facing the youth in our nation. Thank you.
                                 ______
                                 
    Chairwoman McCarthy. Caitlin?

                 STATEMENT OF CAITLIN MONAGHAN,
                   FORMER HIGH SCHOOL ATHLETE

    Ms. Monaghan. Good morning, everyone. Thank you for 
inviting me here today.
    This is a wonderful opportunity and one that I could not 
pass up, because, as I know, concussions are a serious injury, 
and all parties involved in an athlete's life need to know the 
graveness of them.
    I have been a dedicated athlete all my life, playing both 
basketball and soccer from the time I was six years old. I 
loved being active, and, even more, loved being part of a team.
    In many ways, being a serious athlete was expected in my 
town. Parents and children crowded the fields starting from 
Saturday mornings up until Sunday nights, and as we got older, 
our school weeks were filled with long practices and games.
    It was in seventh grade when I experienced my first 
concussion. I had been tripped in a soccer game and ended up on 
the ground only to have an opposing player kick me in the head.
    Though today I don't remember all the details of what my 
parents did or what my coaches did, I do remember suffering 
from headaches and experiencing sensitivity to light for a few 
weeks.
    I rested and was back on the field ignoring any laboring 
symptoms.
    It was not until my senior year of high school when I 
realized the severity of the situation when it comes to 
concussions. It was the fall, and our soccer team was playing 
our biggest rival. To say my teammates and I were pumped would 
be an understatement. And we knew that they would be aggressive 
and fight for every loose ball and commit to every ball tackle. 
We had to do the same to win.
    In the second half I ran to stop an oncoming shot on goal, 
which was kicked from no more than 7 feet away, and I received 
a blow to the side of the head. Within seconds I felt 
disoriented and hit the ground experiencing a blackout.
    Play was not stopped right away because my team did not 
have possession of the ball, but eventually the coaches ran 
onto the field.
    They asked me a series of questions to see if I was alert. 
I was brought to the sideline, given an ice pack and checked on 
once or twice.
    Lying there, I felt nauseous, disoriented, and had a 
pounding headache.
    I was not in a condition to go back with the team on the 
bus so a mother drove me directly home and told my parents 
about what had happened.
    I missed the following day of school due to severe 
headaches and dizziness.
    The symptoms continued over days. Simply put, I just did 
not feel myself.
    My mother took me to my pediatrician to get an opinion. He 
was very concerned and thus recommended that I see a 
neurologist.
    The neurologist ran all the necessary tests and concluded 
that I, in fact, suffered a mild to severe concussion.
    I was prohibited from playing sports until my symptoms 
subsided. I was to see him for further checkups as well as work 
with my high school's athletic trainer, track my symptoms.
    I was alerted to the dangers of second shock syndrome and 
the consequences if I were to get hit again.
    My world was playing sports, and sitting on the sidelines 
was not enough. After two weeks I started to try light running, 
and although the headaches and dizziness continued, I ached to 
get back to playing. To be honest, the pressure to play again 
was amazing.
    It was hard to convince my coaches that I was still 
injured, because when they saw me in school, I was laughing and 
talking with my friends. I seemed fine.
    My teammates also wanted me back and questioned when I 
would return.
    I was back to full play within three weeks of the first 
concussion, even though I was not 100 percent. Headaches lasted 
through practice, and often my sight was blurry, but it was my 
senior year, and since I was not going to continue with soccer 
in college, I wanted to give it everything I had left in me. My 
coaches and teammates deserved that.
    It was during a scrimmage at one of my first practices back 
when I received another concussion. I went to block a shot on 
goal, and, once again, got a blow to the side of the head. 
Feeling very dizzy, I managed to reach the side of the field 
where I laid down on a bench.
    My coaches told me to rest. My athletic trainer was 
notified and rushed to the field. She gave me ice, asked me 
questions, and told me to remain lying down.
    My parents were contacted and I went home.
    My trainer notified me that because of the time that had 
elapsed between both concussions, I could no longer play. I was 
devastated.
    Though I attended every practice and cheered at every game 
until the end of the season, I no longer felt part of the team.
    We returned to the neurologist, and he ran more tests and 
concluded that after two concussions, continuing with any 
physical activity would be dangerous. I was to rest and focus 
on letting my brain heal.
    It was from the time of the second concussion through 
winter break that I noticed the effects of my concussion on my 
school work. The headaches and sensitivity to light, along with 
the loss of concentration, made it hard to pay attention.
    My mother remembers me being very tired and not myself. I 
had been a good student, but my grades started to slip a 
little.
    Though my teachers had known that I was injured, I don't 
think they realized how long the symptoms persisted. I 
participated less and found it hard to concentrate on my 
homework, especially after trying to force myself to 
concentrate through the entire school day.
    Come January I pushed to play basketball believing that I 
was well rested and healed. I was team captain, and though I 
was captain during my junior year as well, I felt that this was 
my year to lead my team.
    My trainer agreed to keep an eye on me. I could participate 
in warm-up drills and over time could play more and more as 
long as I was symptom-free.
    In truth, I was not symptom-free. The fast running and 
jumping that comes along with basketball just brought on worse 
headaches. I would experience blurry vision and dizziness.
    I kept playing, and if it got back I would ask to sub out 
for a quick rest.
    I did, however, realize that aggressive play during games 
could lead to an elbow to the head, or I could be tripped and 
hit my head on the floor, and thus I started to being more 
apprehensive to playing. I would not be as aggressive under the 
hoop and held back taking a charge. I was not playing my best, 
and, therefore, my coach did not play me.
    It was difficult to tell my basketball coach that the two 
concussions I suffered during soccer were still bothering me, 
and that that was the reason I was not playing my best.
    He had been told about the incidents, but did not pay much 
attention to the ramifications. He had been a high school and 
college football player, and thus concussions to him were a 
normal injury that required little rest. I once again sat 
cheering from the side line.
    Though my senior year was wonderful and a time I look back 
on with joy, I know that those two concussions made a huge 
impact on my life.
    On top of the symptoms that eventually eased, I had watched 
two sports seasons end from the bench, had a hard time 
concentrating in schools, affecting my grades, and, above all, 
had felt that I had let many people down.
    I left for college knowing that I would not play sports at 
a collegiate level, and was even weary to kick around a soccer 
ball or shoot hoops with my friends at school.
    Today, I am fine. My world has expanded far beyond soccer 
and basketball, but when I hear the stories of people who have 
suffered from concussions, I am reminded of my own story.
    I believe we need to do a better job advocating for 
athletes, and it starts with educating every party involved: 
Parents, coaches, athletic trainers, teachers, school nurses, 
and the athletes themselves.
    The symptoms, dangers and steps to take when a concussion 
occurs need to be clearly outlined, including regulations 
concerning return to play.
    Conversation needs to start and continue between all 
parties, because, unlike other injuries, concussion can't be 
seen. I can't take off a bandage or hobble around on crutches 
to prove that I am injured. It is only through constant 
communications that symptoms can be monitored or tracked, but, 
unfortunately, that communication can stop when athletes want 
to play again or are pressured to play again from coaches and 
teammates.
    Therefore, a standard school policy is where it starts, but 
certainly not where it ends.
    I thank you for your time and, more importantly, for the 
efforts to bring the severity of concussions to the forefront 
of health issues.
    Chairwoman McCarthy. Thank you.
    [The statement of Ms. Monaghan follows:]

   Prepared Statement of Caitlin Monaghan, Former High School Athlete

    Good morning everyone. Thank you for inviting me here today. This 
is a wonderful opportunity and one that I could not pass up because as 
I know concussions are a serious injury and all parties involved in an 
athletes life need to know the graveness of them.
    I had been a dedicated athlete all my life, playing both basketball 
and soccer from the time I was 6 years old. I loved being active and 
even more loved being part of a team. In many ways, being a serious 
athlete was expected in my town. Parents and children crowded the 
fields starting from Saturday mornings up until Sunday nights and as we 
got older our school weeks were filled with long practices and games.
    It was in 7th grade when I experienced my first concussion. I had 
been tripped in a soccer game and ended up on the ground only to have 
an opposing player kick me in the head. Though today I don't remember 
all the details of what my parents did or what my coaches did, I do 
remember suffering from headaches and experiencing sensitivity to light 
for a few weeks. I rested and was back on the field ignoring any 
laboring symptoms.
    It was not until my senior year of high school when I realized the 
severity of the situation when it comes to concussions. It was the fall 
and our soccer team was playing our biggest rival. To say my teammates 
and I were pumped up would be an understatement. We knew that they 
would be aggressive and fight for every loose ball and commit to every 
ball tackle. We had to do the same to win.
    In the second half, I ran to stop on oncoming shot on goal, which 
was kicked from no more than 7 feet away and received a blow to the 
side of the head. Within seconds I felt disoriented and hit the ground 
experiencing a black out. Play was not stopped right away because my 
team did not have possession of the ball. The coaches eventually came 
onto the field. They asked me a series of questions to see if I was 
alert. I was brought to the sideline, given an ice pack and checked on 
once or twice. Lying there I felt nauseous, disoriented and had a 
pounding headache. I was not in the condition to go back with the team 
on the bus, so a mother drove me directly home and told my parents 
about what happened. I missed the following day of school due to a 
severe headache and dizziness.
    The symptoms continued over days; simply put I just didn't feel 
like myself. My mother took me to my pediatrician to get an opinion. He 
was very concerned and thus recommended I see a neurologist.
    The neurologist ran all the necessary tests and concluded that I 
had in fact suffered a mild to severe concussion. I was prohibited from 
playing sports until my symptoms subsided. I was to see him for further 
check-ups as well as work with my high school's athletic trainer to 
track my symptoms. I was also alerted of the dangers of second shock 
syndrome and other consequences if I were to get hit again.
    My world was playing sports and sitting on the sidelines was not 
enough. After two weeks, I started to try light running and though the 
headaches and dizziness continued, I ached to get back to playing. To 
be honest, the pressure to play again was increasing. It was hard to 
convince my coaches that I was still injured, because when they saw me 
in school I was laughing and talking with my friends, I seemed fine. My 
teammates also wanted me back and questioned when I would return. I was 
back to full play within 3 weeks of the first concussion even though I 
was not 100%. Headaches lasted through practice and often my sight was 
blurry. But it was my senior year and since I was not going to continue 
with soccer in college, I wanted to give everything I had left in me, 
my coaches and teammates deserved that.
    It was during a scrimmage at one of my first practices back when I 
received another concussion. I went to block a shot on goal and once 
again got a blow to the side of the head. Feeling very dizzy, I managed 
to reach the side of the field where I laid down on a bench. My coaches 
told me to rest. My athletic trainer was notified and rushed to the 
field. She gave me ice, asked me questions and told me to remain lying 
down. My parents were contacted and I went home.
    My trainer notified that because of the time that had elapsed 
between both concussions I could no longer play. I was devastated. 
Though I attended every practice and cheered at every game till the end 
of the season, I no longer felt part of the team.
    We returned to the neurologist and he ran more tests and concluded 
that after two concussions continuing with any physical activity would 
be dangerous. I was to rest and focus on letting my brain heal. It was 
from the time of the second concussion through winter break that I 
really noticed the effects of my concussions on my schoolwork. The 
headaches and sensitivity to light along with a loss of concentration 
made it hard to pay attention. My mother remembers me being very tired 
and not myself. I had been a good student, but my grades started to 
slip a little. Though my teachers had known that I was injured, I don't 
think they realized how long the symptoms persisted. I participated 
less and found it hard to concentrate on my homework, especially after 
trying to force myself to concentrate through the entire school day.
    Come January, I pushed to play basketball believing that I was well 
rested and healed. I was team captain, and though I was captain during 
my junior year as well, I felt that this way my year to lead my team. 
My trainer agreed to keep an eye on me. I could participate in warm-up 
drills and over time could play more and more as long as I was symptom 
free.
    In truth, I was not symptom free. The fast running and jumping that 
comes along with basketball just brought on worse headaches. I would 
experience blurry vision and dizziness. I kept playing and if it got 
bad I would ask to sub out for a quick rest. I did however realize that 
aggressive play during games could lead to an elbow to the head or I 
could be tripped and hit my head on the floor and thus I started to 
become very apprehensive. I would not be as aggressive under the hoop 
and held back to taking a charge. I was not playing my best and 
therefore my coach did not play me.
    It was difficult to tell my basketball coach that the two 
concussions I suffered during soccer were still bothering me and that 
that was the reason I was not playing my best. He had been told about 
the incidents, but did not pay to much attention to the ramifications. 
He had been a high school and college football player and thus 
concussions to him were a normal injury that required a little rest. I 
once again sat cheering from the sideline.
    Though my senior year was wonderful and a time that I look back on 
with joy, I know that those two concussions made a huge impact on my 
life. On top of the symptoms that eventually eased, I had watched two 
sports seasons end from the bench, had a hard time concentrating in 
school effecting my grades and above all had felt that I had let many 
people down. I left for college knowing that I would not play sports at 
a collegiate level and was even weary to kick around a soccer ball or 
shoot hoops with my friends at school.
    Today, I am fine. My world has expanded far beyond soccer and 
basketball, but when I hear the stories of people who have suffered 
from concussions I am reminded of my own story. I believe we need to do 
a better job advocating for the athlete and it starts with educating 
every party involved; parents, coaches, athletic trainers, teachers, 
school nurses and the athletes themselves.
    The symptoms, dangers and steps to take when a concussion occurs 
need to be clearly outlined including regulations concerning return to 
play. The conversation needs to start and continue between all parties 
because unlike other injuries concussion can't be seen. I can't take 
off a bandage or hobbled around on crunches to prove that I am injured. 
It is only through constant communication that symptoms can be 
monitored and tracked, but unfortunately that communication can stop 
when athletes want to play again or are pressured to play again from 
coaches and teammates. Therefore a standard school policy is where it 
starts, but certainly not where it ends.
    Thank you for you time and more importantly for the efforts to 
bring the severity of concussions to the forefront of health issues.
                                 ______
                                 
    Chairwoman McCarthy. Mr. Caster?

                STATEMENT OF RICHARD C. CASTER,
                  FORMER NEW YORK JETS PLAYER

    Mr. Caster. Good morning, everybody. Thank you for the 
opportunity to be here, Congresswoman McCarthy, Congressman 
Bishop.
    As you said earlier, my name is Richard Caster. I played 13 
years as a tight end and wide receiver in the National Football 
League, eight of those seasons being here on Long Island 
between the years of 1970 and 1978, and I played for the New 
York Jets.
    I am testifying here today both in my personal capacity and 
as a representative of the National Football League.
    I appreciate this opportunity to be here to testify, 
because I believe that we need to do more to raise awareness of 
the dangers of concussions in youth sports.
    Parents, coaches, teachers and trainers will benefit from 
this hearing and so will their kids.
    A recent study in pediatrics found concussions may be 
double the number of what they were just a few years ago in 
most common youth sports.
    While this could be attributed to the developing science 
around concussions or the increased knowledge of the issue, the 
statistics signal that we as leaders in our community must do 
more to educate, raise awareness and learn to treat these 
dangerous injuries.
    As more has become known about the dangers of head 
injuries, the NFL has chosen to become a leader on concussions, 
not just for the safety of its own players, but for all 
athletes at all levels of football, as well as other sports.
    Last December the NFL, in conjunction with the Centers for 
Disease Control, produced a public service announcement devoted 
to youth athletes as well as their parents and coaches 
regarding the importance of concussion awareness.
    The message aired repeatedly on national media throughout 
the end of the NFL season and the playoffs.
    The NFL has worked closely which with the CDC, USA Football 
and others to disseminate CDC educational materials for young 
athletes and their coaches.
    In addition, USA Football, the independent non-profit 
organization that serves as the official youth football 
development partner for the NFL and its 32 teams, along with 
NFL, will conduct a national campaign from mid-September 
through November 2010 titled Put Pride Aside for Players 
Safety, all to emphasize concussion awareness in youth sports, 
but particularly football.
    The campaign challenges and instructs coaches, parents and 
youth players to make the right decisions when a concussion is 
even suspected.
    Recently the NFL and the CDC have jointly developed an 
educational poster that will be widely available in coming 
weeks on the CDC's website regarding concussions.
    The NFL also mandated that a similar poster be prominently 
displayed in every locker room across the league, and is 
replicating that effort at youth level.
    The NFL hopes to educate as many people as possible about 
concussions with this material.
    Additionally, the NFL has undertaken a state by state 
campaign across the country to pass laws designed to prevent 
the dangerous effects of concussions in youth sports.
    Named after Zachary Lystedt, a stand-out youth football 
player in Washington State, these laws will help prevent the 
most dangerous, damaging results of concussions.
    The laws include three essential elements: One, student 
athletes and any parent or guardian must sign a consent form 
acknowledging that they have been informed about concussions.
    Number two, any youth athlete who appears to have suffered 
a concussion in a sport is not permitted to return to play or 
practice on the same day.
    Three, that athlete must be cleared in subsequent days or 
weeks by a licensed medical professional trained in the 
management of concussions before returning to play or practice.
    Lystedt laws have now passed in five other states including 
Oregon, New Mexico, Connecticut, Oklahoma and Virginia.
    In New York, the bill passed the state senate and is 
awaiting action in the assembly.
    We encourage everyone to support action in the assembly 
this year.
    As part of their state-wide advocacy, the NFL will convene 
an educational and advocacy summit next month in Seattle, 
Washington. It will be available on-line to anyone who is 
interested.
    Finally, I understand that the NFL has been working with 
this Committee to educate and raise awareness, as well as find 
ways to adopt the three simple principles of Lystedt's law 
nationwide.
    The NFL looks forward to continuing to work with this 
Committee and all other advocates for the benefit of youth 
sports everywhere.
    I look forward to any questions.
    Thank you for this opportunity.
    Chairwoman McCarthy. Thank you.
    [The statement of Mr. Caster follows:]

  Prepared Statement of Richard C. Caster, Former NFL Football Player

    Congresswoman McCarthy and Congressman Bishop: My name is Rich 
Caster. I played 13 years as a tight end and wide receiver in the 
National Football League. Eight of those seasons--from 1970 to 1978--
were spent in this area playing for the New York Jets.
    I am testifying today both in my personal capacity and as a 
representative of the National Football League. I appreciate the 
opportunity to be here and to testify because I believe that we need to 
do more to raise awareness of the dangers of concussions in youth 
sports. Parents, coaches, teachers and trainers will benefit from this 
hearing, and so will our kids.
    Participation in athletics teaches our children essential life 
lessons. Team work, the importance of physical fitness, commitment, 
hard work and dedication as well as the benefits of both winning and 
losing are embodied in youth sports. As we teach our children those 
lessons, we also have a responsibility to protect them as much as 
possible from the injuries associated with sports.
    A recent study in the journal Pediatrics found concussions may have 
doubled in the last few years in the most common youth sports. While 
this could be attributed to the developing science around concussions 
or the increased knowledge of the issue, the statistic signals that 
we--as leaders in our communities--must educate, raise awareness and 
learn to treat these dangerous injuries.
    As more has become known about the dangers of head injuries, the 
NFL has chosen to become the leader on concussions not just for the 
safety of its own players, but for all athletes at all levels of 
football as well as all other sports. I am proud of what the NFL has 
done in the professional game, but I am particularly pleased to share 
with you the NFL's initiatives to educate and inform all sports at all 
levels about concussions.
    Last December, the NFL, in conjunction with the Centers for Disease 
Control (CDC) produced a public service announcement devoted to youth 
athletes as well as their parents and coaches regarding the importance 
of concussion awareness. The message aired repeatedly on national media 
throughout the end of the NFL season and the playoffs.
    That was just the beginning. The NFL has worked closely with the 
CDC, USA Football, and others, to disseminate CDC educational materials 
for young athletes and their coaches. In addition, USA Football--the 
independent, non-profit organization that serves as the official youth 
football development partner of the NFL and its 32 teams--along with 
the NFL will conduct a national campaign from mid-September through 
November 2010, titled ``Put Pride Aside for Player Safety'' to 
emphasize concussion awareness in youth sports, particularly football. 
The campaign challenges and instructs coaches, parents and youth 
players to make the right decision when a concussion is even suspected.
    Recently, the NFL and CDC have jointly developed an educational 
poster that will be widely available in the coming weeks on the CDC's 
website regarding concussions. The NFL also mandated that a similar 
poster be prominently displayed in every locker room across the League 
and is replicating that effort at the youth level. The NFL hopes to 
educate as many people as possible about concussions with this 
material.
    Additionally, the NFL has undertaken a state by state campaign 
across the country to pass laws designed to prevent the dangerous 
effects of concussions in youth sports. Named after Zackery Lystedt, a 
standout youth football player in Washington state, these laws will 
help prevent the most damaging results of concussions. Zackery was a 
13-year old star football player who suffered an undiagnosed concussion 
in the second quarter of a game in 2006. After resting during halftime, 
Zackery returned to play in the second half. Tragically, late in the 
game while preventing a touchdown, his helmet hit the turf hard. He 
soon lapsed into a coma after suffering life-threatening injuries.
    Zackery survived, but faces a long road of rehabilitation. In the 
meanwhile, due to a heroic coalition of doctors, advocates and local 
elected officials, the state passed the law named after Zackery. The 
law includes three essential elements:
    1. Student athletes and a parent or guardian must sign a consent 
form acknowledging they are informed about concussions;
    2. Any youth athlete who appears to have suffered a concussion in 
any sport is not permitted to return to play or practice on the same 
day. And;
    3. That athlete must be cleared in the subsequent days or weeks by 
a licensed medical professional trained in the management of 
concussions before returning to play or practice.
    Lystedt laws have now passed in five other states, including 
Oregon, New Mexico, Connecticut, Oklahoma and Virginia. In New York, 
the bill passed the state Senate and is awaiting action in the 
Assembly--we encourage everyone to support action in the Assembly this 
year.
    As part of their state-level advocacy, the NFL will convene an 
educational and advocacy summit next month in Seattle. It will be 
available on-line to anyone interested in learning more.
    Finally, I understand that the NFL has been working with this 
Committee to educate and raise awareness as well as find ways to adopt 
the three simple principles of the Lystedt law nationwide.
    As the most popular sport in the country, the NFL understands its 
obligation to lead in this area. The NFL will continue to provide the 
model for all sports at all levels of sport. The NFL looks forward to 
continue working with this Committee and all other advocates for the 
benefit of youth athletes everywhere.
    I look forward to any questions.
    Thank you.
                                 ______
                                 
    Chairwoman McCarthy. Mr. Hall?

 STATEMENT OF COURTNEY HALL, FORMER SAN DIEGO CHARGERS PLAYER; 
             COFOUNDER, HILLCREST VENTURE PARTNERS

    Mr. Hall. Good afternoon, Chairwoman McCarthy, 
Representative Bishop, and other members of the Committee on 
Labor and Education.
    My name is Courtney Hall. Prior to co-founding Hillcrest 
Venture Partners and receiving my JD/MBA from the University of 
Chicago, I played professional football for the San Diego 
Chargers from 1989 through 1997. I was a second round draft 
choice by the San Diego Chargers and subsequently was a four-
time first alternate to the Pro Bowl.
    Prior to that, I was a collegiate athlete at Rice 
University, where I was two time MVP for the football team and 
a member of the now defunct Southwestern Conference, and a 
1980s All-Decade Team.
    I grew up in Carson, California where I first played tackle 
football for the local Victoria Park Pop Warner football team, 
and then played high school football at nearby Banning High 
School in Wilmington, California.
    I thank you for inviting me to testify at this hearing. I 
also want to thank the Committee for bringing much needed 
attention to the important issue of brain injuries in contact 
sports, especially in tackle football.
    During my playing years from Pop Warner to the NFL, there 
was very little awareness of or attention paid to the dangers 
associated with contact sports.
    I hope that through the work of this Committee, light will 
be shed on the mistakes of the past so that they will not be 
repeated.
    As an offensive lineman, I played football for nearly 20 
years, and for me concussions were always a part of the game. I 
have had many concussions ranging from mild to severe.
    My first concussion occurred when I played Pop Warner 
tackle football. As I was running downfield to cover a punt, I 
tried, unsuccessfully, to run through a defender to get to the 
return man. As I was helped to my feet by my teammates and over 
to the bench, the first words from my coach were ``Are you 
okay?'' His second remark to me was ``Get ready to go back on 
the field. We just recovered a fumble.''
    Throughout my career, I have had many similar experiences, 
be it stumbling back to the huddle after a hit or block, or 
crawling off the field in a daze after an intentional or 
unintentional knee or hit to the head.
    In each of those instances, I did not want to let on to my 
coaches or my teammates that I was impaired due to the warrior 
mentality that was ingrained in me by coaches, teammates, TV 
and others.
    My strangest concussion occurred when I was in the NFL. I 
was running to block a defensive lineman, and as I collided 
with him, I blacked out, but could feel my legs pumping and 
driving so as to keep on my block.
    As the play was over and I stumbled back to the huddle, I 
whispered to my fellow offensive lineman, ``Help me out the 
next couple of plays. My head just got dinged.''
    For each incident, I either returned to play immediately or 
after a couple of minutes of examination and recuperation on 
the side line. The examination usually consisted of cursory 
questions that were asked of all players who experienced 
concussions, questions like ``How many fingers am I holding 
up,'' and ``What day of the week is it,'' but, in reality, the 
ultimate decision to return to the game rested on the desire of 
the player, the coach, and/or how critical the player's absence 
would be to the outcome of the game.
    Hindsight tells me that I should not have returned to the 
playing field under those circumstances. In fact, new research 
into the effects of concussion injuries shows that returning to 
play was not only not in my best interest, but, more than 
likely, made me more susceptible to further injury.
    However, as I am sure still is the case for many football 
players today, I just wanted to be on the field.
    I have not only experienced concussion injuries but have 
also witnessed guys return to the game and seen firsthand how 
they reacted to their injuries. Although these players 
exhibited signs of wooziness and imbalance, as was in my case, 
generally they were still allowed to return to the field.
    As I said before, hindsight tells me that those players 
would have been better off not returning to play so soon, but, 
thankfully, that decision is closer to being placed in the 
hands of an independent third party and not those of the player 
or coach.
    This Committee and the NFLPA should be applauded for 
raising the public's awareness of this issue.
    I particularly want to note the NFLPA's new Player 
Concussion Committee, which will ensure that future generations 
of players, professional and amateur, are provided with the 
knowledge to make the best possible decisions.
    I am delighted and encouraged to see players taking the 
initiative and exerting control over their personal welfare.
    I would also like to commend the NFL on their new policies 
to restrict players who have experienced concussions and other 
brain injuries from returning to the playing field prematurely.
    Football truly is an amazing sport. It is a passion of 
mine, and the lessons I learned have served me far beyond my 
collegiate and professional playing experiences.
    But no sport should unduly endanger the lives of its 
participants. This is especially true for tackle football. I 
recognize that today's athletes are bigger, stronger and faster 
than those of my era, and based on these factors alone, the 
resulting force of the hit is greater than it was in my day.
    With more research into ways to protect players, all of us, 
players, coaches and fans, can continue to enjoy this game for 
years to come.
    Thank you for your hard work on this issue and inviting me 
to this hearing.
    I look forward to answering any questions you may have.
    [The statement of Mr. Hall follows:]

    Prepared Statement of Courtney Hall, Former NFL Football Player;
                 Cofounder, Hillcrest Venture Partners

    Good Afternoon Chairwoman McCarthy, Congressman Bishop and other 
members of the Healthy Families and Communities Subcommittee of the 
Committee on Labor and Education (Committee). My name is Courtney Hall. 
Prior to co-founding Hillcrest Venture Partners and receiving my JD/MBA 
from the University of Chicago, I played professional football for the 
San Diego Chargers from 1989--1997. In 1989, at the age of 20, I was 
the 2nd round draft choice by the San Diego Chargers. Subsequently, I 
became a four-time 1st alternate to the Pro Bowl and was just recently 
a finalist for the 50th anniversary All Time Chargers Football Team. At 
Rice University, I was a two-time MVP for the football team, a 
recipient of the 1988 American Airlines Spirit Award, a member of the 
now defunct Southwest Conference (SWC) 1980's All-Decade Team and an 
inductee into the Rice University Athletic Hall of Fame. I grew up in 
Carson, CA where I first played tackle football for the local Victoria 
Park Pop Warner team and then played high school football at nearby 
Banning High School in Wilmington, CA.
    I thank you for inviting me to testify at this hearing. I also want 
to thank the Committee for bringing much needed attention to the 
important issue of brain injuries in contact sports, especially in 
tackle football. During my playing years, from Pop Warner to the NFL, 
there was very little awareness of or attention paid to the dangers 
associated with contact sports. I hope that through the work of this 
committee, light will be shed on the mistakes of the past so they will 
not be repeated.
    As an offensive lineman, I played football for nearly 20 years and, 
for me, concussions were always a part of the game. I have had many 
concussions, ranging from mild to severe. My first concussion occurred 
when I played Pop Warner tackle football. As I was running downfield, 
to cover a punt, I tried, unsuccessfully, to run through a defender to 
get to the return man. As I was helped to my feet by my teammates and 
over to the bench, the first words from my coach were ``are you okay?'' 
His second remark to me was ``get ready to go back on the field, we 
just recovered a fumble''. Throughout my career, I have had many 
similar experiences * * * be it stumbling back to the huddle after a 
hit or block, or crawling off of the field in a daze after an 
intentional or unintentional knee or hit to the head. In each of those 
instances, I did not want to let on to my coaches or teammates that I 
was impaired due to the ``warrior'' mentality that was ingrained in me 
by coaches, teammates, TV and others. My strangest concussion occurred 
when I was in the NFL. I was running to block a defensive lineman and 
as I collided with him, I blacked-out, but could feel my legs pumping 
and driving so as to keep on my block. As the play was over and I 
stumbled back to the huddle, I whispered to my fellow offensive 
lineman, ``[h]elp me out the next couple of plays. I just got my head 
dinged''.
    For each incident I either returned to play immediately or after a 
couple minutes of ``examination and recuperation'' on the sideline. The 
examination usually consisted of cursory questions that were asked of 
all players who experienced concussions. Questions like ``how many 
fingers am I holding up?'' and ``what day of the week is it?'' But in 
reality, the ultimate decision to return to the game rested on the 
desire of the player, the coach and/or how critical the player's 
absence would be to the outcome of the game.
    Hindsight tells me that I should not have returned to the playing 
field under those circumstances. In fact, new research into the effects 
of concussion injuries shows that returning to play was not only not in 
my best interest, but more than likely made me more susceptible to 
further injury. However, as I am sure is still the case for many 
football players today, I just wanted to be on the field. I have not 
only experienced concussion injuries, but I also have witnessed guys 
return to the game and seen firsthand how they reacted to their 
injuries. Although these players exhibited signs of wooziness and 
imbalance, as was in my case, generally they were still allowed to 
return to the field. As I said before, hindsight tells me that those 
players would have been better off not returning to play so soon, but 
thankfully that decision is closer to being placed in the hands of an 
independent third party and not those of the player or coach.
    This Committee and the National Football League Players Association 
(NFLPA) should be applauded for raising the public's awareness of this 
issue. I particularly want to note the NFLPA's new Player Concussion 
Committee, which will ensure that future generations of players--
professional and amateur--are provided with the knowledge to make the 
best possible decisions. I am delighted and encouraged to see players 
taking the initiative and exerting control over their personal welfare. 
I would also like to commend the National Football League (NFL) on 
their new policies to restrict players who have experienced concussions 
and other brain injuries from returning to the playing field 
prematurely.
    Football truly is an amazing sport. It is a passion of mine and the 
lessons I learned have served me far beyond my collegiate and 
profession playing experiences. But no sport should unduly endanger the 
lives of its participants. This is especially true for tackle football. 
I recognize that today's athletes are bigger, stronger and faster than 
those of my era, and based on these factors alone, the resulting force 
of the hits is greater than it was in my day. With more research into 
ways to protect the players, all of us--players, coaches and fans--can 
continue to enjoy this game for years to come.
    Thank you again for your hard work on this issue and inviting me to 
this hearing. I look forward to answering any questions that you may 
have.
                                 ______
                                 
    Chairwoman McCarthy. Thank you, and thank you for all of 
your testimony which I find fascinating, because we have gone 
across the whole spectrum.
    Being that we are going to be really focusing on our 
students from early grades through high school, Caitlin, I 
would like to hear your opinion, if you have time to think 
about it, from your experience when you were a junior and 
senior in high school, and then in the lower grade when you 
first had the concussion. How do we reach the kids?
    We as adults can stand here, you know, and we can write 
legislation, but there has to be an element of where the kids 
are going to actually listen.
    Does it come from peers? Will it come from a coach? Will it 
come from the trainer? Who would the kids listen to the most?
    Ms. Monaghan. I would say they would listen to their peers 
probably the most. If I had spoken to the athletes in my high 
school now, I think that would help.
    I also think coaches--it is difficult. We want to play 
sports, and we want to compete, and we had trainers that told 
us what the injuries could be, or every injury from ankle 
injuries to head injuries.
    You are given all this information, and we kind of think we 
are invincible.
    I think if you have coaches and peers telling you, ``This 
is what really could happen, and it is a serious injury, and 
you need to discuss it with your parents and everyone,'' I 
think that is the way to go.
    It needs to be easy information that needs to be in sight 
of them. It can't be overwhelming. They have a lot to learn. We 
are absorbing a lot of information in high school, and it has 
to be something that is specific and clear to read so they are 
always notified of the symptoms and causes or anything 
concerning concussions.
    Chairwoman McCarthy. I don't know--because I haven't seen 
them--when the NFL basically comes out with what they are going 
to be putting into lockers as far as looking at and warning 
about concussions, is it going to be graphic or just words?
    Mr. Caster. Congresswoman, I have not personally seen, had 
a chance to see that particular poster, but when it is 
available, we will make sure we get a copy to you. I just 
cannot at this point comment on it.
    Chairwoman McCarthy. I am just curious, because any of us 
that go into a doctor's office and we are waiting for the 
doctor, ``Okay, there is the heart, and here is a healthy heart 
and this is not a good heart.'' People tend to look at the bad 
heart like ``Oh, my gosh, is that the way my heart looks?''
    I am just wondering, Caitlin, would that help if some sort 
of a poster was in the locker room saying ``This is a 
concussion, this is the normal brain, and this is basically a 
brain that has sustained a concussion''--it is simple, but I am 
wondering if that would help to make everyone think a little 
bit more on basically what a concussion looks like, going 
through what an MRI would show?
    Ms. Monaghan. I think it would. I think something really 
visual like that, two different brains.
    At least in our locker rooms in high school, we had a lot 
of words, you know, posters everywhere, but if it was big and a 
graphic like that, a normal brain and a brain that has a 
concussion, I think that would be really helpful, definitely.
    Dr. Queller. I remember when I was in high school, the 
campaign, the ads came out ``This was your brain and this was 
your brain on drugs,'' and it had eggs frying.
    Everybody knows that, and I could definitely see something 
like that making a much bigger impact than a whole bunch of 
words and statistics to these kids.
    If you have a brain and their brain concussed, or even a 
graphic of a scrambled egg, I think that would make much more 
of an impact on an 11-year old kid or 10-year old kid than a 
bunch of words they are not going to read. I wanted to throw 
that in.
    Chairwoman McCarthy. I am going to let you speak, because I 
am going to follow up with you on a number of the suggestions 
that you had.
    One of the constraints that we are going to have on our 
particular committee, unfortunately, is money. Many of us do 
not believe in mandating a lot of things unless we have the 
money to pay for it to come down to the states, because, let's 
face it, our schools are having a tough time meeting their 
budgets at this particular point.
    With that being said, I do believe that there are a lot of 
things that we can put into the language that would basically 
help the schools to start off as far as the educational 
process.
    If you could follow up, Craig?
    Mr. LoNigro. My comment is a little non-related, but I have 
to say that the poster idea is a great way to go. It is a great 
start.
    Gatorade is one of our biggest sponsors with the National 
Athletic Trainers Association based on hydration issues, which 
is a whole 'nother topic, but Gatorade had a nice campaign a 
few years ago. It was a flyer of a urine sample in a container, 
and it just spoke about what color the urine should be of an 
athlete who needs to be hydrated or who is not hydrated.
    When that packet came to my school, I took those posters--
there were about 20 of them in the case--and I plastered them 
all over the school. I had one next to my office, one in my 
office, one in each locker room, the girl's locker room, boy's 
locker room, physical ed locker room. I had one everywhere.
    I cannot begin to tell you how much discussion that this 
brought amongst the kids. The kids see it, they read it, they 
believe it.
    Like you said, when you are in a doctor's office, you are 
waiting around. Sometimes the line outside of my athletic 
training room is eight, ten, twelve kids deep so they are 
reading all the interesting things on my wall so I think that 
is a great start.
    One of the things that I do with my kids when there is a 
concussion or a concussive-related issue, I really take a 
moment to pull the kid aside and really educate them on what is 
going on here.
    I tell them, I say, ``Listen, this is not something where I 
can do a little movement on your knee and tell you that you 
have an ACL tear or do a strength test on your shoulder and 
tell you you tore your rotator cuff. This is something far more 
in-depth.''
    I try to educate them as to exactly what a concussion is, 
and I think that is the important thing too.
    I think the posters are going to help, the education will 
help.
    The CDC, as the Committee knows, has done a great job with 
some of the things that they have produced, and these are two 
hand-outs I give to the kids.
    When I was preparing for this testimony, I just pulled them 
out of my drawer, because I use them frequently, and one is 
Heads Up, Concussions in High School Sports, a fact sheet for 
the athlete themselves to read, and I go over this with them.
    The other is a fact sheet for the parents for what they 
need to look for. It actually comes in different languages as 
well.
    These are some of the things I try to do, is to spend that 
time educating that student and really trying to--take the 
anxiety away and let them know ``This is a serious problem. I 
cannot look inside your head.''
    I know Dr. Queller will agree that they will tell you, 
``Why can't you just clear me?''
    ``You can't be cleared because we don't have any data. We 
don't know based on what we see if you are okay.''
    Another protocol that I have implemented, and it is a great 
tool that I use--and I thank Todd Nelson, who is here from the 
New York State Public High School Athletic Association. They do 
a great job with this concussion issue, and they have been 
great on informing the athletic trainers, but this is a 
checklist that I use. It is a concussion symptom checklist. It 
is in the next folder next to these guidelines.
    What I do is I pull it out. I do my complete evaluation on 
the athlete as soon as the concussion occurs or within the 
closest time that I see them.
    Basically, this athlete is instructed to go home with this 
information if they are picked up by their parents, but the 
opposite side is the physician's evaluation. This would be 
something that would go to Dr. Queller, and we talked about 
this before.
    It is basically an initial evaluation for the physician, 
whoever the physician may be, to provide their observations on 
what they have seen with this student.
    Now, there is a second file--a second column. The first 
column is Initial Evaluation, and the second is Final 
Evaluation, and that column cannot be--that child or that 
athlete cannot compete or re-enter into the athletic activity 
until they have that final evaluation completed by the 
physician, it is signed off and they are cleared to play.
    In answer to your question, I think education is the key, 
and it is going to start with those posters. It is a great 
idea. The kids see it. It catches their eye. If we can come up 
with something a little catchy or a little flashy, it would be 
something that would work.
    Chairwoman McCarthy. Just one more thing. Going back with 
the NFL and the NFLPA, who basically said ``Okay, you guys 
can't go back in''? Did anybody have that right to say you 
can't go back in? Was it the trainer? Can they override the 
coach? Can they override you?
    Mr. Caster. Well, the coach kind of had the last word, but 
the initial information came back from the trainers back when I 
played in the 70s and 80s. That is the way we approached it.
    It was very similar to what Courtney said. Even then, ``How 
many fingers am I holding up? What city are you playing?''
    I got knocked out in Canton, Ohio playing a game--the only 
time I got knocked out--and I vaguely remember the trip, but 
they put me on the plane and flew me back, and I wondered how I 
got where I was going. But I did get back in the game. I 
answered enough questions to satisfy our trainer that yes, we 
were in Ohio, but I looked up at the scoreboard. I saw where we 
were so I got that right, and I guess I guessed on his fingers.
    He said, ``Get back in there,'' and two plays later I was 
out for the remainder of the game.
    It generally came from our trainers, guys that were 
responsible for our health.
    Mr. Hall. In my experience, I guess similar, it really 
boiled down to the player. ``How many fingers are you holding 
up?''
    In a lot of concussions that I have had, the fingers are 
right in front of my face so for me it didn't boil down to 
whether my vision was blurry.
    ``What day of the week is it?'' We only played on Sundays. 
In high school we only played on Fridays. For me that was a 
pretty easy question to answer.
    The only time that I--I can't ever recall being held out of 
a game after I have had a severe concussion. As I said, I 
remember crawling off the field, I remember being on the field 
and having the trainer come out to me and say, you know, ``Are 
you okay? We will come sit you on the side line,'' and at that 
point, when next it was time for me to go back on the field, my 
substitute was getting ready to go back in. I pulled him over 
and said ``No, I am fine. I am ready to play.''
    For me, when I played in high school, college, professional 
athletics, it really came down to myself. The trainer had very 
little say of when I was going to go back on the field.
    I am sure that has changed today, but that is the way it 
was for me.
    Chairwoman McCarthy. Final question to the two of you. So 
basically what we are trying to do, obviously, is to reach the 
youngest of the youngest athletes to try to change the culture 
that you both grew up with. You are the warriors, and you are 
going to go in there, because you love the game. Do you have 
any suggestions on how we can change the culture and at what 
age do we start as far as with the schooling and sports?
    Mr. Hall. I think I gave Chairwoman McCarthy an example. 
When I was younger, my parents were really the driving force 
when I was younger determining when I would play.
    I had a situation where I had broken an ankle. I got my 
cast off that day, and that evening I said ``Great, I am ready 
to play,'' and my mom said, ``No. You are going to sit out.''
    I think a lot of the issues, like the trainer said, is 
really getting the information to the parents. I think that 
also is the first line of defense. They probably can judge the 
athlete, their mood swings, their behavior when they come home, 
how they are behaving, and they honestly have final say, I 
would think, into whether that child is going to play 
subsequently, or if they are well enough to go back on the 
field.
    Mr. Caster. And I would agree with that assessment.
    At a young age, that is the most--I would think the most 
influential people in your lives would be your parent or 
guardian; is to make sure that that information is written down 
and through the processes that we put in place that they know 
what is going on, and along with that information about what 
the adversity is associated with head injuries like 
concussions.
    I think we certainly need a campaign that goes after the 
parents of athletes, that they have a responsibility.
    Beyond that, that is how we begin to change that culture a 
little bit, that it is okay.
    At some point, somebody has to say to the athlete that it 
is okay that these things happen, and not get intimidated by 
the idea of having to sit out or be called a sissy or wuss 
because you didn't get up and tough it out.
    Also, coaches need to counsel their players and their 
athletes too in these situations to help them through it, 
because it is very disappointing, it is a very unfortunate 
moment for them, but it is also disappointing to them because 
in most cases they aren't out there because they had nothing 
else to do, they are out there because they see sports as 
ingratiating their position on campus, with their friends, and 
there is a whole big thing that goes around with that, but 
parents, I would think, would have the best chance if they can 
control their kids.
    Chairwoman McCarthy. Mr. Bishop?
    Mr. Bishop. I want to start with Dr. Queller. You indicated 
that there is baseline testing going on in four high schools 
here on Long Island. Was that initiated by you? Did they come 
to you?
    I am interested in, A, how it started, and, B, how we would 
bring such an activity to scale, how we would get more high 
schools to do that thing.
    Dr. Queller. I have been here only a year. I moved back 
here about a year ago, and that was something I was very 
interested in from the start.
    One of the physical therapists in the area was very 
interested in trying to get a little bit more awareness and 
trying to get some sort of concussion management program.
    When I came here, with his help and my colleagues help, we 
actually kind of went to the high schools. We cover the high 
schools in our area for orthopedic coverage so we thought, 
``Okay, we already have a foot in the door.''
    We actually kind of teamed up with both the athletic 
trainers and the local hospital trying to get some funding for 
it.
    We went to them, and we said ``Look, this is what we are 
offering as a concussion management program, and actually as a 
comprehensive sports medicine program so not only can we treat 
your athletes' broken bones, sprained ankle and torn rotator 
cuff, but we can treat them for head injury.''
    We offered this to the schools, and the schools that bit we 
started that this year, and it has gone very well.
    Mr. Bishop. So your practice has offered this to the 
schools? You are absorbing the cost?
    Dr. Queller. No. We have actually got funding from the 
local hospital to do the baseline testing for them.
    Mr. Bishop. But to bring it to scale--let me back up a 
little bit. What is the cost for the four schools?
    Dr. Queller. When it comes to high school testing, it comes 
out to do baseline testing to about two dollars per test per 
kid, and then post-injury testing, that is easy. That is an 
insurance thing.
    Mr. Bishop. But at least to establish the baseline--look. 
Every dollar is important, but it is not prohibitively 
expensive?
    Dr. Queller. No.
    Mr. Bishop. So this could be something that with the right 
commitment could be brought to scale?
    Dr. Queller. Absolutely.
    Mr. Bishop. I want to go back to Mr. Caster and Mr. Hall on 
the subject that Congresswoman McCarthy is talking about.
    Three of you, Dr. Queller, Mr. LoNigro and you, Mr. Hall, 
made reference to the warrior mentality. You both have competed 
at the highest level of your sport, and I am going to guess 
that in addition to being physically gifted, one of the ways 
that you got there was you had your own warrior mentality, and 
whether you had it because it was innate or whether you had it 
because you knew that that was what coaches were looking for, 
it was an element of your success; am I right?
    Mr. Caster. Absolutely.
    Mr. Bishop. How do we deal with that? How do we deal with 
the sort of innate competitive nature of the highly skilled 
athlete? How do we deal with the innately competitive nature of 
the coach who is looking to be as successful as possible? How 
do we deal with the parents who are perhaps bringing pressure 
to their sons and daughters to be competitive, and not just be 
competitive, but be successful?
    It seems like that is one of the core issues here; that we 
could have the most attentive trainers in the world, but if we 
have this notion that you are a wuss if you sit out, and you 
are going to advance if you go back in, that seems to be a 
really tough issue to get a handle on.
    I would like to hear from both of you on that.
    Mr. Hall. For me, I think it really came to bear, in my 
mind, is when you start looking at the long term effects.
    As an offensive lineman, as I said, concussions for me--
everybody is talking about concussions now. For me, I got my 
head dinged. That was the expression.
    Looking back on it, I understand that a lot of the 
situations I was in, they were concussions, and I suffered 
many, many, mild concussions, and I have had sensitivity to 
light, headaches, which I still have today. That was just part 
of the game.
    But when I started hearing about my fellow offensive 
lineman going through issues, whether it be suicide, Terry 
Long, and some of the other issues--there have been studies 
about the damages of the long term effects of concussions. That 
is really when I started paying attention to it.
    I think, especially as parents--parents, yes, they want 
their kids to be competitive, but if you start telling the 
parents ``You want your kids to be competitive, but these are 
the long term effects if you push your kids too far. They have 
brain injuries, they will have depression, headaches, dementia, 
whatever,'' I think that is when parents will start paying 
attention to it.
    ``Yes, I want my kid to be competitive, but I don't want to 
put my kid in a situation where they are going to have the 
deleterious effects of concussions.''
    I think this also is for athletes as well. Obviously you 
are not going to reach all of them, but when you start showing 
them the long term effects, whether it be in person, video, 
through news article clippings, that I think is when you really 
start paying attention to what are the effects of concussions.
    I mean, that was my experience, anyway.
    Mr. Caster. The idea of the warrior mentality certainly 
starts very early on in our development.
    Your question is a great question, Congressman, about how 
do we deal with it.
    Mr. Bishop. I am full of great questions. I have very few 
answers.
    Mr. Caster. And this one may not have an answer.
    As I ponder it more, and I have been thinking about this 
for a number of years, because I have seen it, you are talking 
about culture. That is the root of this thing.
    To be an athlete on a high school campus, it says 
something. It takes a guy, a young lady to another level. More 
people know them. They are leaders.
    So with all of this, people strive to be there.
    How do I get there?
    To be the tough guy, to be all the things that this culture 
has developed around it, makes it something that everyone 
desires and are reluctant to let it go.
    And so that fight, it certainly has to start back with this 
generation of people coming through and trying to change that 
mentality, because you have pressures, as you said, from 
parents, coaches, peers and so forth. It just continues.
    The warrior mentality is there. It is something that makes 
us feel good, but how we deal with it and take it away, it is a 
bigger answer than I have.
    Mr. Bishop. Thank you. I don't know that it has--it seems 
to me it would take a whole paradigm shift in the way we 
approach competitive athletics.
    Mr. Caster. Exactly.
    Mr. Bishop. Mr. LoNigro, I used to be the chief executive 
of a division 2 college. We had five men's sports, five women's 
sports, and we tried to--we always had every game covered by a 
trainer. We tried to have every practice covered by a trainer 
or training intern; not easy to do.
    What is your experience in terms of high schools in Section 
11? Are they sufficiently staffed to not just cover every game, 
but to at least provide minimal coverage to every practice?
    Mr. LoNigro. That is a great question, and I have to say 
that Section 11, along with the New York State Public High 
School Association, has done a great job in trying to address 
that, specifically with football. I know that it is mandated 
that there needs to be either a physician, an athletic trainer 
or EMT supplied by the home team.
    Mr. Bishop. For each game?
    Mr. LoNigro. For each game, for a varsity game.
    With that being said, I have to also say that Suffolk 
County High School, we founded the Suffolk County High School 
Athletic Trainers Association about two years ago to try to 
develop a kind of medical advisory board such as Dr. Queller 
and Dr. Schrank, and a few other very specific professionals, 
neurologists and orthopedists and skin care physicians to have 
a board that we could refer to.
    Upon our growing of this organization, we are starting to 
realize that Suffolk County is doing a good job, doing a great 
job as far as providing athletic trainers and coverage to our 
high schools.
    As I stand here today as the director of that association, 
I can say that about 90 to 95 percent of the schools in Suffolk 
County are sufficiently covered, or at least supply at least a 
minimum of one athletic trainer to each high school.
    We did have a very interesting situation occur this past 
year with our association. It was a very big topic with us, and 
we took the bull by the horns and we went right after it.
    We had a district who was having a difficult time finding 
an athletic trainer to take that position. They were left with 
no other position but to hire someone in a related field but 
not specifically close enough to really be that person, to take 
care of the athletes in the way that they should. It was not a 
certified athletic trainer. It was not a doctor. It was a 
massage therapist, who is great in what they do. They do a 
great job in their field, but that was not--we felt that it was 
a poor judgment on the part of that district so we fought for 
that.
    There was a maverick parent in the town whose son was 
injured during a football game and was very concerned with the 
care that the athletes were receiving, and it has been taken 
care of since then.
    But this parent went out of his way--and I invited him here 
today. I am not sure if he is here--he went out of his way, and 
he spent tens of thousands of dollars on advertisements out in 
his area, in the news and the print and the radios, and did 
what he could to try to make sure that this issue was 
addressed, and he was very concerned about it.
    It has been addressed, and it has been taken care of.
    In answer to your question, it depends on the county. 
Nassau County as well as is in the same boat. I would have to 
say 90 to 95 percent of those schools are in the position where 
they are hiring athletic trainers.
    I know of one or two school districts in Suffolk County 
which deleted the position based on fiscal issues.
    Mr. Bishop. That is what I am worried about.
    Mr. LoNigro. I have to say, I am in a school district now 
where I serve as athletic trainer along with another athletic 
trainer. We both happen to be teachers in the school, which is 
a great, great situation. Some of the other athletic trainers 
who have one at their high school kind of relish the fact that 
we have this, because it is a great opportunity.
    We only do that because we are teachers there first, and we 
are athletic trainers second.
    Mr. Bishop. My daughter is a middle school teacher, and 
there is a push now within the teacher's center that she is a 
part of for her to become certified in special ed so as to 
expand the skill base that the teachers have.
    Would it be valuable for teacher centers to also establish 
a certification program for teachers in training so that you 
would build a cadre of skilled, trained people that are already 
part of the school?
    You are already part of the school, and in addition you are 
a trainer, right?
    Mr. LoNigro. Exactly.
    Mr. Bishop. Would that be valuable?
    Mr. LoNigro. I think it would. I tell all of my students 
who are--I have a lot of students who have expressed interest 
in the field of sports medicine. I mentor them and tutor them, 
and they cover events with me. I always tell them, I say, 
``Make sure you spread yourself out a little bit. Make sure you 
don't just focus on one particular topic. Get certification in 
other areas. Become a teacher if you like to teach.''
    I have one student who graduated a few years ago, and she 
is ready to come back. She has certification in math, she has 
special ed certification and athletic training.
    That is a great resume to have to present to an athletic 
director or superintendent when you are looking for that type 
of position, especially in a time when we are trying to--when 
money is an issue and we are trying to get the most for our 
money, I really think that that is the way to go, to have dual 
certifications.
    Mr. Bishop. Thank you.
    I have one more question for Caitlin.
    You clearly were imposing some pressure on yourself to get 
back on the field and get back on the court.
    At the time you were going through this, were there other 
athletes that were sort of in the same position as you, and if 
there had been, was that easier for you or would that have been 
easier for you, if some of your peers were also being held out 
for a so-called invisible injury?
    Ms. Monaghan. I definitely think so.
    My season there were not many concussions that I knew of, 
but I think if I knew of them--it is hard being one person out 
of all your friends. The rest of the athletic teams that I was 
friends with, I would say ``I have a concussion,'' and they 
were like ``Okay, you don't feel well.''
    Two weeks later, ``I still have a concussion.''
    ``But you look fine, and you are hanging out with us on the 
weekend so how are you still injured?''
    I think if I had more people that were in the same boat as 
me, sure, that would be helpful, and I think I probably would 
have sat out longer.
    It is hard to convince people when you really want to play 
and you want to be out in the field with your team.
    But I do know football players that later on suffered 
concussions, and they went right back into the game, and they 
had it much worse than I did. They said they blacked out and 
were throwing up on the sidelines, and then went back in.
    When I heard that, I said it is a good thing I sat out as 
much as I did eventually.
    Mr. Bishop. Sounds like these two guys.
    Ms. Monaghan. Definitely more people were in the same boat 
or voiced that they were hit in the head.
    I had a severe concussion, but even a mild to light 
concussion, if I knew other people who had it, I think it would 
have changed my decision, certainly.
    Mr. Bishop. Thank you all very much.
    Chairwoman McCarthy. Just following up on that, Caitlin, 
since you just brought up this story, did you see a difference 
now--because today it is accepted that so many women are in 
sports--is the treatment between your counterparts on the boy's 
football team versus the girl's soccer team or Lacrosse any 
different as far as the trainer goes?
    Ms. Monaghan. It is hard to say. I think because boys play 
football and you think concussion is football, I think it is. 
They are more aware of it in the football arena or game.
    I know my trainer was much more--she spread--was able to 
talk to everyone about it, and if an injury happened, she 
treated us the same, but I think going forward in terms of 
coaches and parents, it is treated differently.
    My parents, I think if I were a boy and playing football, 
they might have been ``Okay, you can go back in,'' but my 
parents were really concerned for me.
    Chairwoman McCarthy. Unless anyone here would like to add 
on to anything that maybe we missed or anything like that--go 
ahead.
    Mr. LoNigro. Just one other thing, Congresswoman. I think 
the grass roots level is the way to go. I know your Committee 
is trying to figure out a plan and how to address it, but I 
think the grass roots level is the perfect place to start, 
because we have a lot of really good sports teams here on Long 
Island in our high schools, football and Lacrosse, and some 
people say what do we attribute to the fact that our Lacrosse 
programs here on Long Island are so great. Well, it is these 
youth programs are phenomenal as well, and they feed into the 
high schools.
    With that same thought in mind, I just think that the 
coaches--I know volunteerism is a dying breed, and it is very 
difficult to attract people to volunteer to coach their young 
kids in sports today. ``We don't have time. Mom is working, dad 
is working,'' but if we could somehow just enlighten those 
youth league coaches as to some of those--even if we make it 
mandatory to have them read through these certain informational 
packages before they become a youth league coach, get certified 
in first aid, CPR.
    I mean, it is just such a basic thing. We should all have 
that anyway, first aid, CPR, and learn how to use an ADD or 
defibrillator on the field.
    These are the people who are around the field all the time. 
They can educate their kids at the same time at an early age so 
that warrior mentality may not be as severe as they get older, 
and the kids may start to be more concerned about their own 
health.
    I was watching an NFL game yesterday. It is funny. My wife 
is also a certified athletic trainer. My kids are athletes, 
very involved.
    We were watching an NFL game yesterday, and there were a 
couple of real devastating hits.
    My two daughters were watching the game, and they said 
``Wow, dad, did you see that hit?''
    My point is one is eight, one is eleven, and they are 
recognizing this, because they are around two athletic trainers 
24 hours a day, and they have a little bit of background.
    But a little bit of knowledge is power, and I think we need 
to take that power to educate just a lay person coach who is 
volunteering after they come home from work to do this for 
their kid, just the slightest bit of education what to look 
for, and hopefully maybe then can get it taken care of at an 
earlier grass roots level.
    Dr. Queller. Kind of dovetailing on that, we at Orthopedic 
Associates, we got together with the Police Athletic League and 
started lecturing, actually, to all of the coaches, which 
usually are also parents, and they made it mandatory that all 
these coaches come out.
    We have given a series of lectures to these PAL coaches, 
and the response rate has been great. They are very concerned.
    And I agree. I think it is one of the places to start, 
because if concussion is on the topic from the very first day 
these kids start hitting, it is going to be reinforced every 
single year, and these seven-year olds become these high school 
athletes. They are going to have heard about concussions for 
ten years and it won't be a foreign concept to them so I 
definitely agree with that.
    Chairwoman McCarthy. You know, think about a lot of the 
initiatives over the years. Seat belts. Yes, I think starting 
on the local level is terrific, but to get the message out 
across the country and then work it from there where it does go 
down, and you start seeing once we have programs in place, 
whether it is posters, educating, then it spreads so it has to 
start, but hopefully someone like yourself or all of you will 
follow through into your areas.
    Tim and I, we are here on Long Island. We deal with our 
schools on a daily basis, but you go to rural areas or you go 
into other--we have to worry about the whole country besides 
our own districts.
    I mean, you have to look at those, especially the rural 
areas or the underserved areas across this country. They are 
not going to get that message, or they are not going to get 
that help that they need also, because our job is to look out 
for all children, and that is what we will do, and then 
hopefully it catches on to a local level.
    I want to thank all of you for coming here and taking the 
time out of your busy days.
    I wanted to say thanks to you, Mr. Castor and certainly Mr. 
Hall, for not only the work that you have done on the field, 
but the work that you have continued to do in your private 
life.
    I know that the Head Injury Association is represented 
here, who has been a great source of us reaching out to get the 
witnesses so I thank you very much.
    Unless someone else has something to say, I think that 
concludes this.
    Mr. Bishop. Thank you.
    Chairwoman McCarthy. As previously ordered, members will 
have 14 days to submit additional materials for the hearing 
record.
    Any member who wishes to submit follow-up questions in 
writing to the witnesses should coordinate with majority staff 
within the requisite time.
    Without objection, this hearing is adjourned.
    [Additional submission of Mrs. McCarthy follows:]

      Prepared Statement of Liz Giordano, Chief Executive Officer,
                        Head Injury Association

    Thank you for this opportunity to submit testimony to the Healthy 
Families and Communities Subcommittee of the House of Representatives' 
Education and Labor Committee regarding the impact of concussions on 
High School athletes.
    I have the privilege to serve as the Chief Executive Officer of the 
Head Injury Association, an independent not-for-profit organization 
dedicated to helping Traumatic Brain Injury survivors maximize their 
potential and help their families return to as normal a life as 
possible. By offering a bridge to hope and healing, we strive to help 
survivors overcome obstacles and move more positively and confidently 
toward the future. We do this by providing the necessary residential 
and community-based programs to help them achieve four valued outcomes: 
Individualization, Independence, Integration and Productivity. We are 
also committed to increasing public awareness of head injuries and 
their consequences and partnering with those who seek to prevent head 
injuries through educational programs.
    Many of the people we serve come to need our assistance as a result 
of a misfortune such as a car accident, an act of violence, or other 
causes beyond their control. Others need our help as a result of the 
unintended consequences of risky behaviors.
    One of the great difficulties in our line of work is addressing the 
regret our consumers and their families often express when they say 
``If only...''
    ``If only'' my child was not at that place at that time.
    ``If only'' my loved one was not involved in that accident.
    ``If only'' they could have received better medical attention 
sooner.
    ``If only * * *''
    As Bob Woodruff described so eloquently in his book ``In an 
Instant'', we have to recognize that life is fragile and subject to 
dramatic change on short notice. Unfortunately for some, once a 
Traumatic Brain Injury occurs there is not much we can do to mitigate 
the consequences of these unexpected and life-changing events and the 
regrets that follow. But when it comes to preventing some head 
injuries, and particularly concussions in youth sports and the 
consequences of what happens after those injuries, there is much we can 
do, and surely we must.
    Recently concussions have been a growing concern among parents and 
coaches of youth sports. During the 2007-08 school year, high school 
athletes alone reported 137,000 concussions and it is believed that 
thousands more went unreported. A concussion can sometimes be difficult 
to detect and often occurs when there is a bump, blow or jolt to the 
head or body which causes the brain to move rapidly inside the skull. 
In many instances an athlete who has suffered a concussion may not 
exhibit symptoms of the injury for minutes or even hours after the 
incident. It is now well understood that not everyone who sustains a 
concussion will lose consciousness. Once a concussion has been 
sustained, however, athletes are at a significantly greater risk for 
``second impact syndrome'', a rare but serious condition that causes 
permanent brain damage or death when a second impact occurs before the 
brain has had an opportunity to heal.
    Earlier this year, Suffolk County passed a local law aimed at 
protecting young athletes and raising head injury awareness. The 
legislation requires county-contracted youth sports agencies to develop 
a written policy to address incidents of possible or actual 
concussions, provide parents with information about concussion 
treatment and management, and prevent athletes from returning to play 
until they are medically cleared. We believe this law could be the 
model for youth sports programs throughout the nation.
    Each March, in observance of National Brain Injury Awareness month, 
the Head Injury Association sponsors a day-long program in which a 
distinguished panel of former professional athletes share their 
personal experiences of concussions and premature return to play. In 
doing so, they give their support to the need for greater awareness, 
regulation and on-going monitoring of athletes who have experienced 
concussions. Speaker after speaker have acknowledged that as athletes, 
they returned to competition sooner after a concussion than they should 
have, simply because they didn't know better. Several speak openly of 
the problems they now face with memory, motor coordination and 
depression, which they attribute to their earlier concussions and 
``post concussion syndrome''. They have been unanimous on a single 
theme:
    ``Knowing what we do today, we can not let this continue. We need 
to act to protect young athletes.''
    Research on concussions among professional football players clearly 
indicates that once a player suffers one concussion he is significantly 
more likely to suffer repetitive concussions. Some former NFL players 
have spoken out publicly that they believe that concussions have 
induced the early onset of Alzheimer's and dementia. Former NFL player 
for the NY Giants, Harry Carson has publicly shared his opinion that 
``Had I known of the neurological damage I would have sustained playing 
professional football, I would have chosen a different career 
instead''. Sadly, until now the research of those who have dedicated 
themselves to studying the long-term impact of concussions on athletes 
has received little support and has been received with remarkable 
indifference. We need to change that.
    Here, on Long Island where youth sports are such a major part of 
our daily lives, it is imperative that we act to maximize our 
children's safety in sports. The same sports designed to enhance 
physical and mental health as well as positive self-esteem can not be 
permitted, even inadvertently, to foster injuries which compromise 
quality of living or even life itself once the games have come to an 
end. I believe the public interest requires your committee to act now 
to protect our young athletes.
    I believe there are steps that can and should be taken to address 
this. Particularly when it comes to the opportunity you have to limit 
the ``second impact syndrome'' caused by impact after a concussion, in 
my opinion you should condition government funding to school and youth 
programs that:
    Regulate safe playing conditions and safety equipment;
    Educate coaches, parents and athletes on the dangers of second 
impacts;
    Establish uniform standards to remove arbitrary and in many cases 
dangerous decisions to allow athletes to return to competition before 
it is medically safe;
    Restrict the exposure of athletes to second impacts without medical 
clearance; and
    Monitor to ensure that regulations actually do protect young 
athletes without unduly restricting competition sports so many enjoy.
    You have the opportunity to eliminate so many ``if only'' regrets. 
I urge you to not let this opportunity to pass you by in a way that the 
next time someone says ``if only'' they finish their sentence with 
``our elected officials had acted to protect our kids''.
    If my testimony helps you to act to prevent even a single head 
injury then I am pleased to have had the opportunity to be heard on 
this important issue. I thank the committee for your attention to this 
serious matter.
                                 ______
                                 
    [Whereupon, at 12:48 p.m., the subcommittee was adjourned.]

                                 
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