 Excellent, Dr. Howell and Dr. Wieb, thank you so much. A couple of quick shout-outs. Since we talked about the Ivy League, Scott Roy from Dartmouth, thanks for joining us. We have a viewing party going on in Virginia, Eastern Time Zone, so two hours ahead of us here in Colorado, a viewing party. That's impressive. Even more impressive, more than 20 people are joined a viewing party in China. On live with us right now, more than 20 people at a viewing party. So thank you, both the Virginians and the Chinese contingent for joining us. And now we'll flip it over to Dustin for Q&A. All right, Dr. Wieb and Dr. Howell, thank you for that excellent session. We've got a ton of questions for you from the audience. The first one comes from our good friend, Dr. Jeff Schild at Texas Children's Hospital or our National Medical Network partners. Dr. Howell, he was interested in your recommendations for neuromuscular training protocols and if there are sport specific recommendations when you implement those. Yeah, that's a good question. I don't know of anything specifically off the top of my head and we're at the very kind of beginning of this research. I think kind of the intention was to try to just better understand if there's something that we could put into return to play paradigms for a concussion that incorporates something other than just aerobic exercise and monitoring symptoms, things like that, maybe get a little bit more formalized with some of the specific training kind of programs that have been established kind of borrowing from other research groups in other areas. So at this point I think no, but there's a lot of work to be done in this area and I think that once we kind of better understand, can there be something that can modulator, I guess reduce the risk of injury for this potentially vulnerable population, this post concussion population. This might be something that we can start to get more sport specific with. Thank you and Dr. Howell, you were able to mention some of the research that's been done by our staff, April McPherson who wrote the increased injury risk. She's one of our young data analysts now after finishing her PhD at Mayo and we do a lot of work with Dr. Wilkerson. Also a lot of people are interested in neuroplasticity, neuro-mechanical coupling protocols. The research of Dustin Grooms is phenomenal for all the people that asked about that. Dr. Wieb, your differences approach on the kickoff, that research model showed huge effect sizes. Some of the audience didn't fully understand what the intervention was. Could you first describe the policy change, why it worked and I think there's good understanding of the policy change is one of the most effective ways to reduce injury. So are there any other policies that you see from your broad database outside of American football that you see as like the next one up that'll be effective and help other athletes? Thanks Dustin, so good to be here with you all. Yeah, in 2016 what happened in Ivy League American football was two things. They moved forward the kickoff line in hopes of giving the kickers a better of chance of landing the ball in the end zone. And if the ball lands in the end zone that incentivizes the return specialist to catch the ball and take a knee which says, I'm not going to try to run this out and their team comes out and starts a fresh. And they also moved the point from which that new play will start as a way to incentivize the receiver further to do that. And so really it was the coaches that said, let's try this because they had observed that they thought disproportionately this team was charging in this direction very hard during a kickoff, this team was charging this hard or in this direction very hard. And from a first look at the numbers, the rates of kickoff return were just really high. So that happened, we wanted to evaluate whether that reduction was more than would occur by chance but of course there's a threat to any study design which is just before and after and that is history. Something else might have happened. So we brought in a control group and that was rates of concussion during non-kickoff returns. And the difference in differences analysis looks at the difference in the exposed group kickoff returns and we saw the line went way down and we subtracted that out from that difference we subtracted the difference in non-kickoff return concussions which was more shallow and flatter. So removing that which would control for other things that may have happened in 2016 we saw that there was a large reduction in that type of play. So kudos to the coaches for doing that and we were so glad to be able to evaluate and put relatively strong numbers behind it. Many other opportunities to evaluate policies in the Ivy League and the Big Ten which are two of the large athletic conferences in the NCAA in the United States. Opportunities to look at lacrosse and how in that sport, men wear different types of equipment in particular helmets and women only wear eye guards and try to gain insight into whether helmets might be protective for women or if there are just other things about the way that games are played which are producing concussions in both women and men. That's one example of an opportunity to evaluate whether apology change could lead to further reductions. Thank you. Dr. Howell, the next question is for you and this is from me. We've been watching your eye tracking research in the past and we've gone down similar routes, I think even studying similar devices. What do you think the current state is of using eye tracking as a concussion assessment and return to play tool? That's a really good question. I think it makes perfect logical sense that the visual system would be disrupted following a concussion. I don't know the exact number but somewhere between 55 and 70% of your brain in some way is related to vision. And so you injure the brain, likely you injure your ability to track with your eyes or some sort of visual disruption whether it's focusing or tracking objects or whatever. So I think it's a very useful component and visual assessment in general that can provide some really, I would say meaningful clinical insights that shouldn't be overlooked. As far as the utility of vision alone, I think it probably contains some degree of diagnostic prognostic and recovery monitoring ability but that's probably for a certain percentage of cases. There's probably a lot of cases that other tests may be useful to use as well. And so that's why I think just that, again, as a piece of that multifaceted assessment, vision should certainly be central and something that everybody considers within their kind of on-field assessment but then also in the clinic when you're cloning people to return to play. And like you said, we're working on ways to develop objective methods to kind of reduce some of that inner tester reliability or even test retest reliability. Some of the issues that have kind of been present that I mentioned briefly from other tests that from the NCWA DOD care consortium has found that kind of common clinical tests including some vision tests have, I would say, or what did they say, less than optimal reliability. So certainly an important part to include. Thank you. And along the lines of new innovations, Dr. Wiebe, you mentioned the guardian cap and I think we have dozens of questions on for more detail on the guardian cap. Do you feel comfortable talking more about that? Happy to talk about it. I have no answers. Colleagues from the study are also texting me wanting to think more about the guardian caps and we have not even started to explore it. I could add, I think a great place to start exploring that would be, I really admired Dr. Rimmer this morning talking about his work in football in Utah and gaining a perspective from the players and coaches on why they think certain things would be happening. And so to put that in more formal terms conducting a mixed method study where we evaluate whether introducing an intervention like that seems to have an effect and whether or not it does talking with the experts, these key stakeholders including athletic trainers to understand that there's definitely something to be learned there and I had too early to say what the answer would be. Thank you and that's a fair answer. Dr. Howell, there's some interest in how people can apply your dual task tests clinically. Are they easily done on a sideline for example? Are there any resources you can give people so they can do that? Could you take that question? Yeah, certainly. So that's a really common question and I realize a lot of the research that kind of I started with was in a 3D motion analysis lab. Like I mentioned, that's not super feasible for most clinicians too. Or we have successfully implemented different dual task approaches in different clinical environments. I have to credit Dr. Julie Wilson who is one of the concussion co-directors at Children's Hospital Colorado for a co-director for our concussion program. She in our sports medicine clinic has kind of encouraged the implementation of routine dual task tandem gate testing for all of our patients over the past year. And so what that entails is we'll have the patient complete the tandem gate test, which if you're not familiar with it is just a three meter strip of tape that you put on the floor and have the person walk as fast as they can in a heel-toe manner down and back. And then really the dual task is intended to compare that kind of single task performance. So you're just focused on the tandem gate test. How fast can you complete this test? And you compare that to something where there's a secondary, a cognitive or some sort of distractor task, a cognitive perturbation. And so what we've been using are kind of easily implementable question and answer tasks. So some tracked numbers by seven, spell a word backwards, say the months backwards, things like that. And so that's been one way that we've been able to incorporate this into our routine clinical practice as kind of an augmentative way to look at postural control and cognition simultaneously. And our initial results are actually pretty promising. They're in review right now, but there appears to be some diagnostic and prognostic value to using this in a sports medicine clinic. So again, less on the sideline, but more seven, we'll say 21 days or so post injury when athletes are coming into us and we want another kind of objective testing tool. It's been useful. We haven't tested it directly on the sideline and I know that there's some of my colleagues across the country that are using it for kind of that same day testing. But I do think that I would encourage clinicians to kind of get creative in your setting to understand what a motor task is and what a cognitive task is and how you could potentially combine those two to get information from both of them independently and then combine, see where the trade-offs are and that might lead to some clinically relevant information. Thank you. And this question will take to each of you and we've only got a couple of minutes. So if you could maybe throw your bullet points at it because it's a huge question is where do you think the most important future directions in concussion research are? Dr. Howell, you're on the cameras. We'll go with you first. Yeah, that's a very big question and I could probably talk for another three hours about that, I won't. I will say my, at least for me, the most interesting thing that I'm currently thinking about is rehabilitation strategy and engaging professionals from different specialties, whether they be physical therapists, athletic trainers, physicians, some of our optometrist colleagues, as you mentioned with vision and how we can identify who can benefit from what treatments. Because concussion is such an umbrella term, there's so many different presentations and there's so many different potential treatments that people may benefit from, identifying those individualized pathways so that we can get athletes back to playing sports and do it in a safe manner. So they're not gonna have these, you know, potential recurrent injuries or new injuries that pop up following this initial event. So on the rehabilitation front, that's certainly where I'm most interested. I wouldn't say it's the most important, that's just my biased opinion. Yeah, and Dr. Howell, that's something we're spending a lot of time on at the USOPC clinically is building tools so we can, like a lot of groups, try to subclassify concussions and do a certain symptom or functional profile, target it with treatments and see if that's better than standard care, which we don't know if that's a waste of time and resources or if it is effective, but it feels like the right thing to do and so we're trying to study that now. Dr. Wiebe, can you talk to us about the future of concussion in your mind? Sure, briefly, for prevention, for a given sport, thinking about, strategic thinking about policy change and practice changes, but also introducing them using randomized designs. I think the field is ready for that in part because so many of the changes we might like to make, the state of whether knowledge on whether that change could be efficacious, we're really in equipoise. We don't know what would be better or worse. There's still little evidence. We could pursue some of these questions with a randomized trial. Also, in part because I think that observational studies get dinged, unduly so, in part just because people know the mantra that it's observational, there must be problems with the study. So I will stop there with that one, but then for recovery, what I'd like to really see evaluated is we have evidence from this study that athletic trainers are doing very well at following consistent guidelines to have a concussed athlete proceed through the steps accordingly for return to exertion and return to practice and return to full play. I would really like to, I'm very interested in return to learn relative to return to exertion and which one might come first to lead to better outcomes. So I think that's a question that remains in the field and I'd love to see that explored. And I think there's a chance to do that with this study too. Yeah, you bring up some great comments that like I said before, policy change doesn't sound cool, doesn't have a lot of sex appeal, the word policy change, but the effect sizes are massive. And so we should probably go down that route because it's proven to work. Okay, thank you both. Thank you, Dr. Howell. Thank you, Dr. Weeb. We are going to take it back to Charlie. Charlie, you ready? Ready as I'm gonna be. Excellent. Thank you, doctors. Thank you, Dustin. That was awesome. Appreciate it. Love the pen shirt, Dr. Weeb. So we remember trivia polling, we got a couple, one medicine question, one Olympic question coming up. So please pull during the break. As a reminder, to SPRI and the U.S. Olympic and Paralympic Foundation, private resources are critical for us to implement and expand programming in the research area, as well as preventative sport medicine. So any considerations on making a donation, just go to the link on the trailer and you can make a donation to SPRI and or the U.S. Olympic and Paralympic Foundation. Enjoy your break. A quick shout out to Tandis Howley from UCLA Athletics. Tell Lisa Fernandez she is still the greatest female leader in Olympic sport I've ever met in my life, three-time Olympian, and also Miami University of Ohio. Having a viewing party? You guys are awesome. Thanks for joining us.