[Senate Hearing 113-903]
[From the U.S. Government Publishing Office]





                                 ______



                                                        S. Hrg. 113-903
 
                     STATE OF PLAY: BRAIN INJURIES
                         AND DISEASES OF AGING

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             JUNE 25, 2014

                               __________

                           Serial No. 113-24

         Printed for the use of the Special Committee on Aging
         
         
         
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              U.S. GOVERNMENT PUBLISHING OFFICE 
 46-915 PDF          WASHINGTON : 2023
            
             
             
             
                       SPECIAL COMMITTEE ON AGING

                     BILL NELSON, Florida, Chairman

ROBERT P. CASEY JR, Pennsylvania     SUSAN M. COLLINS, Maine
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ORRIN HATCH, Utah
KIRSTEN E. GILLIBRAND, New York      MARK KIRK, III Illinois
JOE MANCHIN III, West Virginia       DEAN HELLER, Nevada
RICHARD BLUMENTHAL, Connecticut      JEFF FLAKE, Arizona
TAMMY BALDWIN, Wisconsin             KELLY AYOTTE, New Hampshire
JOE DONNELLY, Indiana                TIM SCOTT, Scott Carolina
ELIZABETH WARREN, Massachusetts      TED CRUZ, Texas
JOHN WALSH, Montana
                              ----------                              
                  Kim Lipsky, Majority Staff Director
               Priscilla Hanley, Minority Staff Director
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Bill Nelson, Chairman...............     1
Opening Statement of Senator Susan M. Collins, Ranking Member....     2
Opening Statement of Senator Elizabeth Warren, Committee Member..     3

                           PANEL OF WITNESSES

Christopher Nowinski, Former Professional Wrestler, World 
  Wrestling Entertainment, Founding Executive Director, Sports 
  Legacy Institute...............................................     4
Ben Utecht, Former National Football League Tight End, Cincinnati 
  Bengals and Indianapolis Colts.................................     6
Jacob W. Vanlandingham, Ph.D., Director of Neurobiological 
  Research, Tallahassee Memorial Healthcare Neuroscience Center, 
  and Assistant Professor, Florida State University College of 
  Medicine.......................................................     8
Robert A. Stern, Ph.D., Professor of Neurology, Neurosurgery, 
  Anatomy and Neurobiology, Clinical Core Director, BU 
  Alzheimer's Disease Center, Boston University School of 
  Medicine.......................................................    10

                                APPENDIX
                      Prepared Witness Statements

Christopher Nowinski, Former Professional Wrestler, World 
  Wrestling Entertainment, Founding Executive Director, Sports 
  Legacy Institute...............................................    28
Ben Utecht, Former National Football League Tight End, Cincinnati 
  Bengals and Indianapolis Colts.................................    32
Jacob W. Vanlandingham, Ph.D., Director of Neurobiological 
  Research, Tallahassee Memorial Healthcare Neuroscience Center, 
  and Assistant Professor, Florida State University College of 
  Medicine.......................................................    34
Robert A. Stern, Ph.D., Professor of Neurology, Neurosurgery, 
  Anatomy and Neurobiology, Clinical Core Director, BU 
  Alzheimer's Disease Center, Boston University School of 
  Medicine.......................................................    38

                        Questions for the Record

Christopher Nowinski, Former Professional Wrestler, World 
  Wrestling Entertainment, Founding Executive Director, Sports 
  Legacy Institute...............................................    49
Ben Utecht, Former National Football League Tight End, Cincinnati 
  Bengals and Indianapolis Colts.................................    54
Jacob W. Vanlandingham, Ph.D., Director of Neurobiological 
  Research, Tallahassee Memorial Healthcare Neuroscience Center, 
  and Assistant Professor, Florida State University College of 
  Medicine.......................................................    56
Robert A. Stern, Ph.D., Professor of Neurology, Neurosurgery, 
  Anatomy and Neurobiology, Clinical Core Director, BU 
  Alzheimer's Disease Center, Boston University School of 
  Medicine.......................................................    70

                       Statements for the Record

Testimony of Jeff Miller, Senior Vice President, National 
  Football League................................................    81
National Football League, Health and Safety Report 2012..........    86
National Football League, Health and Safety Report 2013..........   116
Testimony of the National Association of State Head Injury 
  Administrators.................................................   156
                         C  O  N  T  E  N  T  S

                              ----------                              

                   Statements for the Record (cont'd)

Testimony of Walter J. Koroshetz, M.D., Deputy Director, National 
  Institute of Neurological Disorders and Stroke, National 
  Institutes of Health...........................................   160
Testimony of Amy Comstock Rick, CEO, Parkinson's Action Network..   172
The American Academy of Neurology, Talking Points................   175
The American Academy of Neurology, Press Release-Ben Utecht......   177
Dr. Ann C. Mckee and Meghan E. Robinson, Ph.D., article published 
  on behalf of The Alzheimer's Association, ``Military-related 
  Traumatic Brain Injury and Neurodegeneration''.................   179
Article published from Alzheimer's and Dementia written by Victor 
  L. Villemagne and Nobuyuki Okamura.............................   191


                     STATE OF PLAY: BRAIN INJURIES



                         AND DISEASES OF AGING

                              ----------                              


                        WEDNESDAY, JUNE 25, 2014

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 1:17 p.m., Room 
562, Dirksen Senate Office Building, Hon. Bill Nelson, Chairman 
of the Committee, presiding.
    Present: Senators Nelson, Blumenthal, Warren, Donnelly, and 
Collins.

                  OPENING STATEMENT OF SENATOR
                     BILL NELSON, CHAIRMAN

    The Chairman. Good afternoon. Today, we are going to have 
to be a little creative because we are going to have a series 
of votes at 2:30, so, what I will do is recess the Committee 
and we will go over and vote until the very last vote, and we 
will cast the vote at the very beginning of the last vote and 
then race back over here so that we can continue the hearing.
    There is also some breaking news. Just an hour ago, the NFL 
agreed to eliminate the $675 million cap on concussion-related 
claims available to thousands of players as part of a major 
lawsuit, and so, without objection, I will enter the NFL's 
statement in the record.
    Part of what we are going to discuss today is traumatic 
brain injuries--a bump, a blow, a jolt to the head or a 
penetrating head injury that disrupts the normal function of 
the brain. More mild TBIs, more commonly referred to as 
concussions, have been the center of increasing discussion 
within the sports community in recent years as a growing number 
of current and former athletes say that they are suffering from 
memory loss and other impairments caused by repeated blows to 
the head, and, of course, we are seeing the TBIs that are 
coming home from overseas with our men and women in uniform in 
the performance of their duties, as well.
    The Centers for Disease Control and Prevention have looked 
at 1.6 to 3.8 million sports and recreation-related TBIs, and 
they say that they occur in the U.S. each year. Such head 
injuries are not limited, obviously, just to one sport. They 
occur in a wide range of sports, and most recently, we were 
reminded of that in the story in the New York Times with the 
graphic pictures of the games going on in Brazil right now, in 
which one of the soccer players was completely knocked out.
    Over the last few years, much has been done to increase 
awareness of the risk posed by sports-related concussions, and 
thanks to a number of partnerships and initiatives, research is 
underway to help us better understand the cause and the long-
term impact of concussions and what we can do to prevent them. 
These initiatives involve a number of organizations, so, while 
we are making progress, it is important to note that much more 
research is needed and to see all of the links to other things, 
such as Alzheimer's.
    Today, we are going to hear from two former professional 
athletes who had their careers cut short due to concussions, 
and now they are going to wonder about their function in the 
future. We are going to take testimony from two prominent 
medical researchers who will discuss the latest research, and I 
am going to give that privilege of introduction to Senator 
Warren after I turn to our great Ranking Member, Senator 
Collins.

                  OPENING STATEMENT OF SENATOR
                SUSAN M. COLLINS, RANKING MEMBER

    Senator Collins. Thank you very much, Mr. Chairman.
    I very much appreciate your calling this important hearing 
so that we can better explore the relationship between 
traumatic brain injury and diseases associated with aging, such 
as Alzheimer's, Parkinson's, and Lou Gehrig's disease, also 
known as ALS.
    Traumatic brain injury, or TBI, affects five million 
Americans at an annual cost of more than $76 billion. As the 
Senate Co-Chair of the Alzheimer's Task Force, I am 
particularly interested in the research conducted over the past 
three decades that has linked moderate and severe traumatic 
brain injury to a greater risk of developing Alzheimer's 
disease and other forms of dementia.
    One troubling study cited by the Alzheimer's Association 
found that older individuals with a history of moderate 
traumatic brain injury are more than twice as likely to develop 
Alzheimer's than are seniors with no history of brain injury. 
Those with a history of severe traumatic brain injury were 
found in this study to have a 4.5 times greater risk.
    Finding a way to prevent and effectively treat Alzheimer's 
disease is among my highest priorities as a Senator and has 
been a focus of this Committee's work. In many ways, 
Alzheimer's is the defining disease of the Baby Boom 
generation. If we are to prevent it from becoming the defining 
disease of the next generation, we must strengthen our 
commitment to research leading to a better understanding of 
this devastating disease.
    While researchers still have a great deal to learn about 
how head injuries affect an individual's risk of developing 
neurological diseases like Alzheimer's later in life, there is 
increasing evidence of a relationship. Women, even more than 
men, may be even more likely to experience long-term symptoms, 
such as cognitive and visual impairments, after sustaining a 
severe head injury. We know that, currently, almost two-thirds 
of Americans living with Alzheimer's are women.
    There are many important research projects being conducted 
on TBI and the link to neurological diseases. For example, the 
National Institutes of Health and the National Football League 
have embarked upon a $60 million, four-year, public-private 
partnership to advance research that may lead to the 
improvement of TBI diagnoses through better imaging 
technologies and also improved treatment for those who have 
sustained serious head injuries.
    Indeed, while those who have participated in contact sports 
or served in the military may face a particular risk for TBI 
and related health conditions, the leading cause of TBI among 
seniors is falls. According to the CDC, individuals over age 65 
have the highest rates of TBI-related hospitalizations and 
death.
    More research is required to establish definitively the 
link between head injuries and neurological diseases, but it is 
clear that this important research could lead to a better 
understanding of such devastating diseases as Alzheimer's, 
Parkinson's, and ALS. This critical research could also benefit 
our veterans and troops on the ground, far too many of whom 
have experienced TBI and its painful, lasting effects.
    Again, Mr. Chairman, thank you for holding this hearing. We 
have a great panel of witnesses and I look forward to getting 
their insights and learning more about the current research on 
this topic.
    The Chairman. Thank you, Senator Collins.
    I want to especially recognize Kevin Turner. Kevin was a 
star fullback at the University of Alabama. He played eight 
seasons with the New England Patriots and the Philadelphia 
Eagles in the 1990s. Since being diagnosed in 2010 with ALS, 
Lou Gehrig's disease, Kevin has worked tirelessly to raise 
awareness about the disease and its possible connection to 
traumatic brain injuries, and so, Kevin, we thank you very much 
for being with us here today. Thank you.
    Senator Warren, if you will introduce two of our panel.

                 OPENING STATEMENT OF SENATOR 
               ELIZABETH WARREN, COMMITTEE MEMBER

    Senator Warren. I will do that. Thank you very much, Mr. 
Chairman and Ranking Member Collins, for having this hearing 
today.
    I am pleased to have the opportunity to introduce Dr. 
Robert Stern and Chris Nowinski, Co-Directors of the Boston 
University Center for the Study of Traumatic Encephalopathy.
    Dr. Stern is a Professor of Neurology and Neurosurgery at 
Boston University School of Medicine and he is the Director of 
the Clinical Core of the Boston University Alzheimer's Disease 
Center. He received his undergraduate degree from Wesleyan 
University and his Master's and Doctoral degrees in clinical 
psychology from the University of Rhode Island. Before joining 
the Boston University School of Medicine, he served on the 
faculty of Brown Medical School and the University of North 
Carolina School of Medicine. Dr. Stern's research has led to 
more than 250 peer-reviewed publications and has helped us to 
better understand the effects of trauma and aging on the human 
brain.
    Now, he is here today with Mr. Nowinski, who is the Co-
founder and Executive Director of the Sports Legacy Institute. 
This is a nonprofit organization that is focused on addressing 
the issue of brain trauma through education, through policy, 
and through research. He received his undergraduate degree from 
Harvard University, where he played defensive tackle for the 
football team, and, after college, Mr. Nowinski became a 
professional wrestler, and his own experience in that sport 
with head trauma led him to co-found the Sports Legacy 
Institute. He currently serves as an advisor on the NFL Players 
Association Mackey-White Traumatic Brain Injury Committee and 
the Ivy League Multi-Sport Concussion Committee. Chris has 
received numerous accolades, including the United States Sports 
Academy Distinguished Service Award for his work advocating for 
improving safety standards in sports.
    I am very pleased that Dr. Stern and Mr. Nowinski are here 
with us today. I know they will add enormously to our 
discussion, so thank you both.
    Thank you, Mr. Chairman.
    The Chairman. It is my pleasure to introduce Ben Utecht, 
who is a former NFL tight end for the Cincinnati Bengals and 
the Indianapolis Colts, and, if I recall, you were on one of 
those teams that went into the playoffs, and perhaps you can 
tell us the rest of that story.
    Dr. Jacob VanLandingham is the Director of Neurobiological 
Research at Tallahassee Memorial Hospital and he is a professor 
of Florida State University's College of Medicine.
    What we will do, we will start with you, Mr. Nowinski, and 
just go right down the list. Your written statement is entered 
into the record, so if you would just share with us for a few 
minutes and then we will get into questions. Mr. Nowinski.

           STATEMENT OF CHRISTOPHER NOWINSKI, FORMER

             PROFESSIONAL WRESTLER, WORLD WRESTLING

             ENTERTAINMENT, AND FOUNDING EXECUTIVE

               DIRECTOR, SPORTS LEGACY INSTITUTE

    Mr. Nowinski. Thank you for that wonderful introduction, 
Senator Warren.
    Chairman Nelson, Ranking Member Collins, and members of the 
Committee, thank you for inviting me to speak today. My name is 
Chris Nowinski, Founding Executive Director of the Sports 
Legacy Institute, a nonprofit organization dedicated to solving 
the sports concussion crisis through advocacy, education, 
policy, and research.
    I also have a personal relationship with concussion and 
tremendous concerns that I have increased my risk of developing 
a degenerative brain disease in the future. It is my hope that 
this hearing raises awareness of the urgent need for funding 
for research on traumatic brain injuries as well as the 
tremendous opportunities we have for the prevention of their 
long-term consequences.
    I never had a second thought about concussions or brain 
injuries until I was 24 years old. After playing contact sports 
in high school and then at Harvard, I became a pro wrestler, 
technically known as a superstar, with WWE, and I got to travel 
the world playing a bad guy or a hell known as Chris Harvard, 
who would creatively insult the fans' intelligence and cheat to 
win. Let me remind you, this is a character I played. I rarely 
cheat anymore, and, it was a performance to entertain our fans 
and it was a lot of fun.
    In a match, I was kicked in the head by my opponent and my 
world immediately changed. My head became throbbing. Everything 
got foggy, and, most importantly, I forgot the script. I could 
not remember how we were supposed to finish the match, and, 
honestly, that was terrifying. After the match, I was stopped 
by our athletic trainer who asked if I was all right, and, I 
lied and I said, ``I am fine,'' even though the headache was 
killing me.
    The symptoms then expanded beyond daily headaches to 
include depression and sleepwalking and they would not go away, 
but I lied about my symptoms for five weeks, thinking I was 
doing the right thing.
    I finally met Dr. Robert Cantu, eventually my SLI Co-
founder, who helped me understand that all the dings and all 
the bell-ringers I had been getting over the years were 
actually concussions. To think that at 24, I was learning for 
the first time how fragile my brain was and how critical rest 
was after a concussion, and that I am now at higher risk for 
developing a degenerative brain disease. My ignorance cost me 
my career. It cost me at least five years of my health, with 
terrible post-concussion syndrome, and I do not know what it is 
going to cost me in the future.
    CTE, chronic traumatic encephalopathy, is what I fear most. 
It was first named ``punch drunk'' in 1928 and then largely 
ignored. In the last decade, we have realized that it obviously 
affects--that we have known it affects boxers, but now we know 
it affects other athletes, military veterans, even members of 
the general public. Since we cannot diagnose it in living 
people, we do not know how many people have it, but early 
evidence indicates it is not insignificant.
    At our VA-BUSLI Brain Bank, a collaboration with the CT 
Center at Boston University and the VA Boston Health Care 
System led by Dr. Ann McKee, 58 of the 62 brains of former NFL 
players studied have been found positive for this disease, and 
athletes as young as 17, and she has also--Dr. McKee has also 
connected to motor neuron disease, and I want to mention, 
having my friend Kevin Turner here in the room, who 
courageously is taking on this issue. I will defer the rest of 
the science to my colleague, Dr. Stern.
    The reality is, we need answers quickly. We do not know how 
big this problem is, but it may be massive, with 1.7 million 
TBIs a year, at least 3.8 million concussions, and, we have to 
recognize that contact sports are constantly evolving and we 
still do not know what the full life effects are of exposing 
children to repetitive brain trauma, because the sports seven-
year-olds played in the 1950s are not the ones that we are 
playing today, and, football helmets were different, so players 
did not hit each other in the head. Soccer was not as popular, 
so we do not know what the effects of a lifetime of headers 
are. Until Title IX, few women were playing contact sports, so, 
we do not know these answers, but it is a public health crisis.
    While we work to independently fund more work, and we 
applaud the State laws that have changed how we play sports, it 
is not enough. We do not know--you know, one of the things I do 
is I train WWE's wrestlers on concussions, which is fun. Before 
they get in the ring, they now have to listen to me, but, we 
think we can train adults, even though it is difficult. We do 
not know if we can train children, and, so, the reality is, we 
do not know. We have kids playing contact sports who do not 
recognize when they have a concussion, who will never have a 
doctor on the sidelines, and that means, with all the changes 
that we have made, CTE will continue to be a problem for 
athletes and most certainly will be a problem for our military 
veterans.
    A new initiative that we announced today that we hope will 
help prevent this, we teamed up with the Santa Clara Institute 
of Sports Law and Ethics on a campaign to educate parents and 
coaches on the risks of heading in soccer before high school. 
We were joined by Women's National Team players--former 
National Team Players Brandi Chastain, Cindy Parlow Cone, and 
Joy Fawcett, who won the 1999 World Cup, along with our Medical 
Director, Dr. Cantu, to say the reality is we do not need these 
headers to happen. The current guideline is ten. It may start 
even earlier for many kids, but, it should not happen.
    To conclude, we must not underestimate the long-term impact 
of brain injuries. With one in four boys and one in 16 girls in 
America playing contact sports, we are putting a lot of 
children at risk for CTE. We owe them, as well as our military 
veterans, greater investment into finding ways to effectively 
minimize the negative consequences of this inevitable brain 
trauma.
    Thank you.
    The Chairman. Thank you, Mr. Nowinski.
    Mr. Utecht.

            STATEMENT OF BEN UTECHT, FORMER NATIONAL

             FOOTBALL LEAGUE TIGHT END, CINCINNATI

                 BENGALS AND INDIANAPOLIS COLTS

    Mr. Utecht. Well, first of all, thank you so much for this 
opportunity. It is truly a privilege to be here before you to 
speak about something that has impacted my life in ways that 
are very scary and unknowns that, as a husband and father, have 
put me in a situation where I do not know what my future is 
going to look like.
    As a river kid from a small town in Minnesota, Hastings, 
Minnesota, I do not know how it happened, but I found my way 
into the NFL, six years. I had an opportunity to play in the 
Super Bowl Championship of 2006 with the Indianapolis Colts, 
before I went on to play two years with the Cincinnati Bengals. 
I am now a husband and a father of three beautiful girls, so, 
thankfully, I do not have any football players in the family 
right now, but the new perspective of a father has really 
become a part of my life.
    Right now, I have just taken the National Spokesperson 
position for the American Academy of Neurology, which is the 
largest association of neurologists in the world. Twenty-seven-
thousand now make up the Academy. They are the leaders in 
neurology in the world, along with their national foundation, 
the American Brain Foundation, whose goal is to cure brain 
disease through exactly what Chris talked about, the importance 
of raising money for research.
    I hope I never forget the night of February 4, 2007. It was 
an amazing night in Miami, Florida, as we stepped onto the 
Dolphins Stadium, onto the biggest stage in the world. I do not 
even know how to put it into words to describe it to you. Over 
100 million people tuned in to watch the Indianapolis Colts 
face off against the Chicago Bears.
    I will never forget, two weeks prior, our All-Pro kicker, 
Adam Vinatieri, telling the team, ``Don't you dare blink at 
kickoff.'' Now, Adam has already won three Super Bowls, so he 
has quite the experience, but, there I am on the field, 
standing in between future Hall of Fame quarterback Peyton 
Manning and future Hall of Fame coach Tony Dungy, and I 
remember Adam's words. ``Don't you dare blink at kickoff.''
    There Adam is, walking off the steps. The whistle blows. 
His hand drops, and he releases the players, and he places his 
foot on the ball and I have never in my life seen so many 
flashing lights. I mean, it would rival the experience of Neil 
Armstrong. It truly felt like I was dancing with the stars. It 
was the greatest experience of my life. We won the game, 29 to 
17, and forever, I will be able to wear this ring on my finger 
in remembrance of that game. It was a dream come true.
    Two years later, that dream was shattered when I woke up 
face down on a training camp field in Georgetown, Kentucky, 
being strapped to a board and put onto an ambulance because of 
my fifth documented concussion. For the first time in my life, 
my brain became a priority, and, the reason why it became a 
priority is because at 29 years old, I started to have memory 
problems, and, it took losing my mind to care about my mind.
    My memories began to fade away. In fact, one story I have 
shared is going home to Minneapolis and spending time with 
friends of ours. My wife and I were sitting around a table, and 
Matt, my friend, brought up his wedding and I said, ``Well, why 
was I not able to be there,'' and I got the strangest look from 
him, and, the table got quiet and his wife brought over their 
photo album from their wedding, and page after page, there I 
was as a groomsman in his wedding, and I sang a song in his 
wedding, and I have no memory of that experience. It is 
completely gone.
    Then, there are behavioral changes. There is hearing my 
five-year-old daughter tell our family practice doctor that, at 
times, she is afraid of me. As a father, it puts the idea of 
the effects of traumatic brain injury on a completely different 
level.
    I cannot help now but throw myself into a new target, 
neurology, to tackle a new opponent, brain disease, and 
particularly traumatic brain injuries and concussions. I have 
been impassioned through advocacy to fight for lives being 
ripped apart by brain disease, Alzheimer's, Parkinson's, 
epilepsy, and chronic traumatic encephalopathy.
    We need a national revival of funding to go into these 
issues so that we can find the answers. You, as Senators, can 
really become our new coaches. You can help decide the game 
strategy, put in the countless hours of work and research into 
creating policies that can change this nation, connecting 
people to their most valuable asset, their mind. It is not just 
education and awareness, but it is changing the nature of a 
person. It is getting them to truly care so that they can take 
the education and awareness and implement it because they are 
passionate about who they are, which comes from their brains.
    I will not stop in the pursuit of finding cures for brain 
disease and creating an emotional connection between the world 
and neurology, because neurology, our neurologists who cradle 
the miracle that makes us human, our brains. It is time for all 
of us to realize how special our brains really are.
    I have a number of policies I would love to share with you 
in question and answer time. Thank you.
    The Chairman. Thank you, Mr. Utecht.
    Dr. VanLandingham.

          STATEMENT OF JACOB W. VANLANDINGHAM, PH.D.,

             DIRECTOR OF NEUROBIOLOGICAL RESEARCH,

          TALLAHASSEE MEMORIAL HEALTHCARE NEUROSCIENCE

            CENTER, AND ASSISTANT PROFESSOR, FLORIDA

              STATE UNIVERSITY COLLEGE OF MEDICINE

    Dr. VanLandingham. Thank you, Mr. Nelson, and thanks to the 
Committee for giving me the opportunity to speak today about 
traumatic brain injury.
    I am a researcher. In 1995, I had my own personal 
experience with brain injury. I was not playing football. I was 
actually assaulted. I was down in Gainesville and there was a 
vagrant who assaulted me and I had three hemorrhages in my 
brain. I spent two weeks in intensive care and 18 months with 
amnesia. I was one of the lucky ones. I got my memory back. 
Most people who experience what a lot of us have experienced 
are not that lucky.
    I went on to do a degree, a Ph.D., in neuroscience and 
focus on research. Most of my clinical and basic research over 
the last 17 years has been focused on traumatic brain injury. 
Recently, I put--the last five years--more focus into 
concussions and mild traumatic brain injury.
    To give you a little background, after--what causes a 
concussion is the brain sort of slings forward and is 
accelerated, and it is going to hit against the inner skull on 
the frontal part of the brain and then it is going to be kicked 
back the other way, and it is going to go through this sort of 
acceleration, deceleration, rattling inside the skull.
    A lot of people think that the brain is only damaged by 
hitting the inner part of the skull, but actually, the brain is 
sort of like Jell-O and it stretches. The accelerating frontal 
portion of the brain goes faster than that back portion of the 
brain and it stretches the brain in between, and it is that 
stretching that causes a sort of breakdown in metabolism in the 
brain and it makes it where the brain's functions are slower. 
Electricity does not run in the brain quite as well as it used 
to. When we have had a concussion, often, we will be able to 
get to the right answer. We are just delayed. Our thought 
processes are delayed in getting to that correct answer.
    I think it is important that we also note that not only are 
we having concussions in athletics, we mentioned the military 
earlier, we mentioned the elderly and the falls epidemic that 
we have in the elderly, and we also have a problem with falls 
in children. We do not want to forget the pediatric population. 
By midnight tonight, nearly 30 children in this country will 
die from a traumatic brain injury, and, a lot of folks will 
continue--a lot of these kids--to have problems for the 
remainder of their life, so, it is very important that we put 
the focus across the age span, across the lifespan, if you 
will.
    If we think about pediatric traumatic brain injury, we will 
notice that they often take a lot longer to get better after a 
concussion. What may take an adult like myself seven to ten 
days to get better, it may take them seven to ten months. They 
get behind in school. They do not graduate with their fellow 
schoolmates. A lot of issues with pediatric brains that are 
different and need to be respected as different when coming up 
with treatments when compared to the adult. The same goes for 
the elderly.
    When we think about sports, we always go to the NFL and 
professional sports. I believe that we have an even worse 
problem, if you will, in high school athletics because it is 
still an immature brain. The brain is not fully developed. If 
you do not have a fully developed brain and it is injured, it 
has a harder time recovering. That means if we have got a high 
school player playing football who is 240 pounds--still big--
hits with a tremendous amount of force, and is engaging in 
having head contact with an immature brain, and that makes it 
that much worse.
    After you have a concussion, most everybody thinks if you 
go rest, you just get better. About 20 percent of people do not 
get better. They end up with what is called post-concussion 
syndrome, which Chris alluded to earlier and how that ruined 
his career. It takes months to years to get over post-
concussion syndrome.
    What we also see when we have post-concussion syndrome is 
we see a lot of sleep difficulties. If I had a dime for every 
person I knew that had had a head injury that had sleep 
problems--and the sleep problems, we never recognize that. We 
never put effort into trying to improve sleep patterns, and 
that is such a huge part of getting better, getting the 
appropriate sleep at night so that brain can repair.
    Unfortunately, concussions are notorious for being 
difficult to diagnose and treat. Each injury may have a 
different constellation of findings, and these findings can be 
very subtle. While each injury may be subtle and unique, the 
common factor is that when folks are injured and they are 
athletes or they are in the military, they do not want to 
actually tell the truth. They want to sort of intentionally 
mask it.
    The same thing goes with an elderly patient. An elderly 
patient does not want to lose their independence. They are not 
engaged in wanting to give up driving or whatever it may be. 
The World Health Organization has stated that as the lifespan 
increases, we are going to see that TBI will surpass many other 
diseases as the major cause of death and disability by the year 
2020.
    In conclusion, I would like to say that TBI transcends 
generations and populations, from the infant to the elderly. A 
concussion is compounding. If you have one concussion, you are 
more likely to have two, and so on and so forth. In my 
professional opinion, we are dealing with two major research 
and development issues--two. First, because concussions are 
compounding, we need to develop new acute pharmaceutical 
treatments. We treat everything else with drugs. Why do we not 
put a focus on developing a drug for this condition. If we can 
give an acute treatment after a concussion, we can reset the 
brain, cure it at that point, and then it is not a compounding 
issue. You are not more likely to get a second concussion, and 
so on and so forth.
    The other thing that we are up against, and I know Dr. 
Stern will speak more to, is the issue of chronic traumatic 
encephalopathy, Alzheimer's disease-like pathologies. These 
pathologies are also being seen down in the spinal cord and 
leading to Lou Gehrig's disease, or anterior lateral sclerosis. 
We need to put a precedence on developing drugs that can stop 
this pathology, so, we need to stop concussions in the 
beginning, prevent it from being compounding, and then we need 
to put a focus on new drugs that can stop or halt the 
progression of the pathologies associated with chronic 
traumatic encephalopathy.
    Our company, Prevacus, is currently developing an acute 
treatment for concussion. We will design it as a field 
deliverable. It will be a nasal inhalant to get more of the 
drug to the brain, and a medic, an ambulance technician, an 
athletic trainer can give it immediately and we can stop the 
pathological consequences in their tracks. We also hope to be 
developing two new neurosteroid drugs this summer, which will 
be focused on Alzheimer's and Lou Gehrig's disease.
    I would like to thank you once again for the time you have 
given me to speak. Thank you, Senator.
    The Chairman. Thank you, Dr. VanLandingham, and, we have to 
deal with issues up here like the cuts in funding to NIH and 
having to restore those, so, we are very sensitive to what you 
say.
    Dr. Stern.

         STATEMENT OF ROBERT A. STERN, PH.D., PROFESSOR

              OF NEUROLOGY, NEUROSURGERY, ANATOMY

          AND NEUROBIOLOGY, CLINICAL CORE DIRECTOR, BU

               ALZHEIMER'S DISEASE CENTER, BOSTON

                 UNIVERSITY SCHOOL OF MEDICINE

    Dr. Stern. Good afternoon, Mr. Chairman, Ranking Member 
Collins, and distinguished members of the Committee. It is a 
great honor to appear before you today.
    My name is Dr. Robert Stern. I am a Professor of Neurology, 
Neurosurgery, and Anatomy and Neurobiology at Boston University 
School of Medicine. I am also the Director of the Clinical Core 
of the Boston University Alzheimer's Disease Center, one of 29 
centers funded by the National Institute on Aging.
    For the past 25 years, I have been conducting clinical 
neuroscience research into issues pertaining to the aging 
brain, in particular, Alzheimer's disease. Since 2008, my 
research has focused on the long-term consequences of 
repetitive brain trauma in athletes. In particular, I have been 
studying the neurodegenerative disease chronic traumatic 
encephalopathy, or CTE. CTE is a progressive brain disease that 
can lead to dramatic changes in mood, behavior, and cognition, 
eventually leading to dementia. It is similar to Alzheimer's 
disease, but it is a unique disease, easily distinguished 
through post-mortem neuropathological examination.
    Originally called ``punch drunk'' or dementia pugilistica 
in the early 1900s, when it was believed to only occur in 
boxers, CTE has now been found in individuals from age 17 to 
98, including youth, college, and professional contact sport 
athletes, such as football, hockey, soccer, and rugby players.
    Research suggests that in some individuals, repetitive 
impacts to the head trigger a cascade of events leading to a 
progressive destruction of brain tissue, and these changes in 
the brain can begin years or even decades after the last trauma 
or after the end of athletic involvement, and can lead to 
memory loss, poor judgment, impulse control problems, 
aggression, rage, depression, suicidality, movement problems, 
and, yes, dementia.
    I have had the great privilege and honor to interview the 
family members of approximately 100 deceased former athletes 
who were diagnosed with CTE after death by my colleague, Dr. 
McKee, and her team. From these interviews, I have begun to 
learn about the clinical course and presentation of this 
disease, but more importantly, I have learned about the 
tremendous pain and suffering the family members experienced 
while their loved one's life was destroyed by CTE.
    I have also been privileged to meet over 70 former NFL 
players who have come to Boston to participate in my NIH-funded 
DETECT study. I hear their stories. I speak with their family 
members, and, I listen to their fears that they have CTE or 
that their fellow former football players have or will get the 
disease. They have all witnessed firsthand the tragic downward 
spiral of CTE that sadly seems to have become an expected 
consequence of playing the game they loved.
    The goal of the DETECT study is to develop objective 
biological tests, or biomarkers, to diagnose CTE during life. 
Just as a separate note, right now, today, in the next half-
hour, the first NFL player--former NFL player in our study is 
going to undergo a very exciting new PET scan that is designed 
to detect the abnormal deposition of the tau protein found in 
this disease in a human being while they are alive. That is 
happening this afternoon.
    This will, hopefully, improve our ability to diagnose CTE, 
and that, indeed, the ability to diagnose CTE during life, is 
the next critical step. It will lead to the ability to answer 
important questions about this disease, such as how common is 
it? What are its risk factors? How can it be prevented? How can 
we treat it? In other words, at this point, we actually know 
very little about this disease.
    One thing we do know is that concussions are just the tip 
of the iceberg. You have been hearing today a lot about 
concussions. We have been hearing a lot about concussions in 
sport and in the military, but, the thing I am most concerned 
about are what we refer to as sub-concussive blows, or hits to 
the head that rattle the brain and likely do the same type of 
thing that Dr. VanLandingham has mentioned to those neurons, 
but without causing the same symptoms of concussion, and, those 
can happen many, many more times than anyone ever expects, a 
thousand to 1,500 times in a typical football lineman, perhaps 
a thousand times during heading in a season in soccer. That is 
what scares me.
    In order to tackle the complex issue of CTE, we must expand 
upon current approaches to conducting research in 
neurodegenerative disease. We must break down the traditional 
silos of individual research labs, institutions, and 
disciplines, and begin to conduct multi-disciplinary, 
collaborative research across research centers, bringing 
together the very best scientists, novel methodologies, and 
state-of-the-art technology.
    I fear that we have a major public health crisis looming 
and we must act now. Alas, as you have been hearing, this 
requires tremendous financial support, and, as all of you know 
all too well, current NIH funding is, indeed, tragically low.
    I want to express my gratitude toward this Committee for 
leading the recent effort in increasing NIH funding for 
Alzheimer's disease research. However, we must now have 
additional funding to support research focusing on CTE, and, 
because of their similarities, new discoveries about CTE will 
inform and expand our knowledge of other neurodegenerative 
diseases, like Alzheimer's, Parkinson's, and Lou Gehrig's.
    In closing, many of our most cherished games in our 
country, such as football, hockey, and soccer, often involve 
repetitive blows to the head, potentially leading to a 
progressive brain disease. We must learn as much as possible as 
quickly as possible in order to determine who may be at 
increased risk for CTE and to develop methods of preventing and 
treating the symptoms of CTE.
    I want to close by thanking the Committee for your interest 
in addressing this important issue and for your commitment 
toward improving the health and well being of older Americans. 
Thank you.
    The Chairman. Thank you, Dr. Stern.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    First, I want to thank all four of our witnesses for truly 
exceptional testimony.
    Mr. Utecht, your statement was so moving and so riveting. 
You mentioned during the course of your comments that when you 
were strapped to that stretcher, that was your fifth documented 
concussion. What happened after the previous four? Were you 
treated each time? Did you try to conceal that you had had a 
concussion, such as Mr. Nowinski mentioned? Tell us what 
happened.
    Mr. Utecht. Sure. Thank you for those questions. A number 
of answers. Have I ever concealed that I have had a concussion? 
Yes, I have. There is tremendous pressure in professional 
sports to want to continue to play, not only you do not want to 
let down your teammates, who become your family, you do not 
want to let down your coaches, who you work countless hours 
with to put together a successful plan, and an injury can 
remove you from that plan and you do not want that to have an 
effect on the team, and, so, yes, I was put in a position where 
I wanted to play and I--and that pressure kept me from being 
honest, and I regret that.
    Each concussion got worse, as the doctors have talked about 
today. My third concussion was simply a player jumping over me 
in pursuit of a tackle, as his foot lightly braised my helmet 
and I was knocked out unconscious for 20 seconds. I have 
watched the film and I see myself get up and run off to the 
sideline, and I have no memory of that. It was the first time I 
had ever experienced amnesia, and that was midway through the 
first quarter against the Denver Broncos in 2007, and I do not 
remember anything from that game until we went in at halftime, 
and, that really became--once the time that I began 
experiencing short- and long-term memory issues, which led into 
my final concussion that was an eight-month rehabilitation 
process.
    Each team at that time was set up differently. For the 
Indianapolis Colts, they did have a neurosurgeon who was one of 
our team doctors who treated the players that had concussions. 
In Cincinnati, it was a neuropsychologist who treated players 
with concussions, and, so, I think that is really one of the 
things we have really wanted to change, is making sure that 
players are actually seeing a neurologist who are those that--
are the experts that can diagnose and manage concussions 
properly.
    Senator Collins. Mr. Nowinski, the comments we have just 
heard remind me of when I first learned about the link between 
traumatic brain injury and neurodegenerative diseases, and it 
was when I met with a neurologist from Maine, Dr. Bruce 
Sigsbee, who had a patient come to him who was a veteran and he 
was being treated for post-traumatic stress syndrome at the VA 
in Maine, and, the doctor, the neurologist asked him if he had 
ever had a concussion, and it turned out that he had had 
several concussions and traumatic brain injuries while he was 
in Iraq, and, he had been misdiagnosed as having post-traumatic 
stress when, in fact, he had a TBI, and, it turned out that the 
TBI was causing him, or caused him to have a form of epilepsy, 
which the neurologist then treated him for.
    My question to you is, is it your experience that patients 
with neurodegenerative diseases often have a difficult time in 
getting a proper diagnosis?
    Mr. Nowinski. Thank you, Senator, Collins, for that 
question. It is a great question, and the answer is there is no 
question that former athletes are having a very hard time 
getting the right diagnosis, because CTE is so new that we are 
not--we have not been training for it in medical school and it 
has been widely ignored in continuing education, and, so, I 
mean, interestingly, when you go through our Brain Bank 
records, most everybody who eventually Dr. McKee diagnoses with 
CTE was originally diagnosed with Alzheimer's, or an abnormal 
type of Alzheimer's, or some other similar disease, but almost, 
you know, until the last couple years, it was none of whom were 
getting CTE as a diagnosis, meaning that they were probably 
being mistreated.
    As Dr. Stern alluded to, how just horrible this disease is 
for the individual and especially their families, it is 
important that we at least do a better job of trying to treat 
them while they are alive so that they can live a better life, 
because--and that is something that I hope for myself, because 
I am 35 now and the average onset of symptoms is usually for 
these people in their 40s, so, there is not that much time left 
for me and there are certainly ticking clocks for a lot of 
people.
    Senator Collins. Thank you.
    Dr. Stern, I was struck when I heard you talk about the new 
imaging, and you mentioned that individuals with CTE have the 
tau protein, and, I know from my work on Alzheimer's that the 
tau protein is present in the brains of people with 
Alzheimer's, also, so, are we talking about the same protein, 
and is there a link here?
    Dr. Stern. That is a wonderful question, and it is one of 
the things that is so exciting about working in this disease, 
because there is a definite link, but yet they are completely 
distinct. The difference is that in Alzheimer's disease, there 
are two proteins that start accumulating in an abnormal fashion 
and it is an abnormal form of those proteins. One is called tau 
and one is called amyloid, and, in CTE, we do not see the 
amyloid, and when we do see it, it is not in the same kind of 
plaques that we see in Alzheimer's disease, and, so, CTE is 
very specifically a tau disease, and, the type of formation of 
the tau and the places in the brain where the tau starts to 
accumulate is quite distinct from what we see in Alzheimer's 
disease.
    To answer the question, we have to understand that we 
cannot right now diagnose these neurodegenerative diseases 
accurately while people are living, including Alzheimer's 
disease. We have been studying Alzheimer's disease since 1905, 
when it was first discovered, and yet we still cannot truly 
diagnose it during life, but, fortunately, we are getting very, 
very close, in large part to the help that this Committee has 
given to support research, but, we still cannot do it.
    With CTE, we have only been studying it really in depth for 
the last five, six years, but, what we are able to do, and what 
we are doing with my research right now, is exploiting what we 
have learned with Alzheimer's disease to learn about CTE, so, 
studying the tau now with a method that was originally 
developed for Alzheimer's disease and other neurodegenerative 
diseases, we can quickly come to answers about CTE.
    Senator Collins. Thank you.
    The Chairman. Well, is there something that we need to be 
aware of with regard to helping you in the experimentation on 
living patients?
    Dr. Stern. Yes. Money, money, money. That is what it comes 
down to, but, it is not just the responsibility of the Federal 
Government. This needs to be a partnership of the Federal 
Government, foundations, and the private sector. These types of 
research studies and to answer the questions the right way cost 
tremendous amounts of money, and in order to get to some 
answers quickly, we must have the adequate resources to do so.
    Indeed, we need continued assistance in increasing the 
budgets, not just reducing the cuts, but increasing the budgets 
at the National Institutes of Health for neurodegenerative 
disease research in general, but, I would hope for and ask you 
to start a special line of research for supporting chronic 
traumatic encephalopathy so we can really understand the 
distinction between this disease that may affect countless 
people in the future and diseases that have already been 
receiving funding, like Alzheimer's disease.
    The Chairman. Senator Blumenthal.
    Senator Blumenthal. Thank you, Mr. Chairman, and thank you 
for having this very important and enlightening hearing, and 
thank you to the members of the panel for contributing so 
importantly to our discussion, and each of you has really been 
extraordinarily insightful in your own way, based in part on 
the experience and the research that you bring to this table.
    Just to add to the Chairman's question, money, money, 
money, is often very important, but it is also how the money is 
spent----
    Dr. Stern. Yes.
    Senator Blumenthal. [continuing]. Also, what can be done to 
prevent CTE. One of the areas is education.
    Dr. Stern. Yes.
    Senator Blumenthal. The Korey Stringer Institute at the 
University of Connecticut has released, as you know, a list of 
nine recommendations for lessening the incidence and reducing 
the long-term effects of traumatic brain injuries, and the 
experience of the States in adopting those recommendations is 
very, very mixed. Connecticut has implemented only four. Most 
other States have implemented fewer of them, so, there is a lot 
of work to be done here in educating parents, trainers, but 
also public officials as to what can be done.
    You know, one of the areas of injury that was unknown to me 
concerns horseback riding, which is, in fact, the leading cause 
of sports-related traumatic brain injuries out of all the 
recreational sports. Think of it, horseback is the leading 
cause of sports-related traumatic brain injuries. Why? Because 
a lot of young riders are wearing helmets made of velvet with 
no real protection. Think of a football player wearing a velvet 
helmet, nothing more.
    In fact, I am planning to introduce a measure which I am 
naming for a young woman, Christen O'Donnell from Darien, 
Connecticut, who was thrown from a horse while riding, suffered 
a traumatic brain injury, and died the next day. She wore one 
of these traditional velvet hunt caps, and it was sold 
alongside safety-certified helmets, but her parents had no idea 
that they were buying a velvet decorative helmet rather than a 
real protective gear.
    The bill that I will introduce, Christen O'Donnell 
Equestrian Safety Helmet Act, would require equestrian helmets 
produced and sold in the United States to meet minimum safety 
standards. I do not want to go too much into the details 
because I have a limited amount of time, but I want to thank 
you for the support in terms of the factual background that you 
provided for this kind of measure, which I think can be 
replicated in other sports areas, as well, and I am sure that 
we will be talking about them in the near future.
    I would like to ask Mr. Nowinski, you are now 35. Your 
injury occurred when you were 24. How are you feeling now?
    Mr. Nowinski. Well, thank you for asking, Senator 
Blumenthal. I--it is up and down. I mean, these days, I still 
get way more headaches than I would like to. The last two days 
were actually very tough. Today, right now, I feel pretty good, 
but, you know, as part of Dr. Stern's Legend Study, I did my 
annual phone call, longitudinal study testing my cognition, and 
there was stuff I was proud of and there was stuff that I did 
not feel so good about, so, I am happy where I am, but I am 
always wary of where I am going.
    Senator Blumenthal. The kick in the head that caused your 
injury was, in a sense, a routine part of the sport, correct?
    Mr. Nowinski. It was an accident. We are not supposed to 
actually do that, just so you know.
    Senator Blumenthal. But, accidents in that sport----
    Mr. Nowinski. Sure.
    Senator Blumenthal. [continuing]. Frequently occur. In 
fact, they are sort of part of the routine, because--well, you 
say it in your own words, but when you are in a contact sport 
of that kind, particularly where the routine, so to speak, is 
to actually do damage, at least fake damage----
    Mr. Nowinski. Right.
    Senator Blumenthal. [continuing]. To another person, it is 
easy to make a mistake, just like if you are throwing a fake 
punch, if you do it in the wrong way, you are going to hit the 
person----
    Mr. Nowinski. A real punch.
    Senator Blumenthal. [continuing]. With a real punch, so--
and this must have happened to you repeatedly before that one. 
As you say in your testimony, you suffered repeated blows to 
the head in the course of sports and so forth. In your 
experience, are people in that sport--call it a sport for the 
moment----
    Mr. Nowinski. Mm-hmm.
    Senator Blumenthal. [continuing]. WWE Wrestling, or similar 
kinds of sports, aware of this repeated impact and effect of 
the routine blows that are struck?
    Mr. Nowinski. Actually, yes. WWE has become actually a 
close partner in the last few years with SLI. We actually 
honored them with our annual Impact Award last year because 
they have become a real leader on this issue.
    Senator Blumenthal. And you actually participate in some of 
the educational sessions.
    Mr. Nowinski. Right. I got to--I go back and train the 
whole roster, and then when they hire new wrestlers, I come 
down and train them on concussions before they get in the ring. 
They made a $1.2 million unrestricted gift to support our 
research at Boston University, so, it has been very rewarding 
to see that culture change so quickly so that the people--and 
many of them, my friends, are still wrestling there--are in a 
much safer place and they have protections in place that will, 
hopefully, minimize the risk of long-term damage.
    Senator Blumenthal. In terms of the contact sport area 
generally--and any of the other folks on the panel should feel 
free to comment, as well--how is the insurance coverage for 
that sport and others, so far as you know, relating to this 
kind of injury, which, as you have just said very dramatically 
and compellingly, is not just a one-month or a one-year 
recovery period, but it can be, literally, a lifetime.
    Mr. Nowinski. Yes. You know, it is difficult for me to 
speak to all insurance programs because I know there have been 
a lot of changes, especially very recently, in many sports to 
provide for more medical care long-term, but, I think you make 
a good point that it is just extraordinarily expensive to deal 
with these consequences long-term, so I can pass that down the 
panel, but it is a significant issue.
    Senator Blumenthal. Thank you.
    Dr. VanLandingham. I will comment real quick. We have HMOs 
in the State of Florida that will not even reimburse for a 
concussion diagnosis, even in the Tallahassee area, the largest 
HMO. To get reimbursement, we have to come up with other 
things, like claim that there is memory impairment, and we get 
reimbursed based on that code, but, there is still not a 
specific code, and multiple HMOs that will not even reimburse 
this concussion in the civilian world.
    The Chairman. Is that true in Medicare, as well?
    Dr. Stern. In Medicare, people are definitely supported for 
dementia-related conditions and assessments, but, often, what 
we are seeing with this disease of chronic traumatic 
encephalopathy is that it does not present exactly the same way 
as Alzheimer's disease and other dementias. There could just be 
really dramatic behavioral changes, or mood changes, without 
the memory problem initially, and, in those cases, they might 
be treated as having a psychiatric disease or illness, and, so, 
the funding is quite different in those cases and much more 
limited.
    The Chairman. Senator, before I return to you, I want to 
get an understanding of how could concussions have an effect 
upon Lou Gehrig's disease, ALS, that our special guest is 
afflicted with.
    Dr. Stern. Again, I just want to underscore that it is not 
necessarily concussions. It is the overall repetitive brain 
trauma, including all those sub-concussive hits that do not 
result in someone at all being knocked out or having changes in 
symptoms. It is the little hits over and over again that may 
start this cascade of changes in the brain cells that lead to 
the deposition of this abnormal tau that leads to the 
destruction of the brain as people live longer.
    What we have seen is that in some cases, the abnormal tau 
and another protein called TDP-43 is not just in the brain of 
an individual with a history of repetitive trauma, but it also 
is in the spinal cord, and in those cases, it leads to the same 
types of alterations in motor functioning, in strength and 
weakness, as one would see in run of the mill ALS.
    It is not that it leads to the same type of ALS that might 
be caused by another underlying factor. It results in the same 
type of motor neuron disease caused by repetitive brain trauma, 
is what we currently think.
    The Chairman. Senator, please continue.
    Senator Blumenthal. Thank you. You know, Mr. Chairman, you 
are very, very gracious. I am over my time, out of my time, and 
I am going to yield to some of my colleagues in light of the 
vote that we have coming up, but thank you very much.
    The Chairman. Senator Warren.
    Senator Warren. Thank you very much, Mr. Chairman and 
Ranking Member.
    Research at places like Boston University that focus on 
traumatic brain injury has revealed that athletes and veterans 
with chronic traumatic encephalopathy, or CTE, exhibit 
structural changes to their brains that are similar to the 
patterns of brains from people with Alzheimer's disease and 
that the patients exhibit similar symptoms, and, I know we have 
been talking some about this, but I want to ask the question a 
little bit differently.
    We do not know the root causes of these conditions because 
not everyone with a history of head trauma develops CTE, and 
not everyone develops Alzheimer's disease as they age, but, we 
also currently lack effective diagnostic tools or treatments 
for either disease, so, the question I would like to ask for 
Dr. Stern and Dr. VanLandingham is how can you use what you 
learn about traumatic brain injuries to inform the study of 
other age-related neurodegenerative diseases? Dr. Stern.
    Dr. Stern. Senator Warren, thank you for that question. 
That is the question that led me to get involved in the study 
of chronic traumatic encephalopathy. As an Alzheimer's 
researcher, I was never really interested in traumatic brain 
injury, except one day I happened to be giving a lecture saying 
that traumatic brain injury was a risk factor for dementia, and 
Chris Nowinski's roommate was in the audience and we then 
connected and it led me to find out about what was a burgeoning 
topic of this chronic traumatic encephalopathy.
    The reason why I got excited about it was just for that 
reason, that it is a close enough cousin to Alzheimer's and 
other diseases that had been studied that it could--we could 
exploit what we find out about one to learn about the other.
    Senator Warren. Mm-hmm.
    Dr. Stern. With chronic traumatic encephalopathy, we know 
the necessary variable for developing this disease. The 
necessary variable is repetitive brain trauma----
    Senator Warren. Right.
    Dr. Stern. [continuing]. Like you very articulately said. 
That is not the sufficient variable. Not everyone who hits 
their head is going to develop this disease, but, we know that 
everyone who has this disease has had a history of repetitive 
brain trauma.
    By that nature, we are able to then look at a group of 
people at high risk, very high risk for developing this disease 
and study them longitudinally and use new diagnostic tests to 
be able to detect when the disease might start and then follow 
them until death and have my colleague, Dr. McKee, and other 
neuropathologists examine them.
    That is a very unique thing. In Alzheimer's disease, we do 
not have that ability. We do not know who is at very high risk 
for getting it until later on, when we might be able to do now 
a special kind of PET scan that can detect the amount of 
amyloid in their brain. Well, now, we can use both sides of 
this picture to inform the other and make us get to answers so 
necessary in a much faster fashion.
    Senator Warren. Dr. VanLandingham, did you want to add 
anything to that?
    Dr. VanLandingham. Yes. Well, just reiterate a little bit 
that no one brain is the same. One of the most common questions 
I get from parents are, well, when should I make my son or my 
daughter stop playing this sport? How many concussions? And, 
you know, I am, like, well, everybody is different. You know, 
you would like to say, well, after three, they are predisposed 
to CTE, so, it is a very complicated answer, but I agree with 
Dr. Stern that it is a special population that can be measured 
in the years to come and you will get closer to the right 
answer.
    I would like to add one more comment to the Lou Gehrig's 
issue. I work--I do a lot of pre-clinical research with animals 
and we can give concussions, even one single concussion to an 
animal, and we find the tau protein in the cerebral spinal 
fluid, and, that fluid not only bathes the brain, but also it 
bathes the spinal cord, so, it could be an issue of transferral 
from the brain that has been damaged of these pathological 
proteins down into the spinal canal and some level--but we do 
not know yet, but, it is definitely bathing the spinal cord 
after a brain injury.
    Senator Warren. Well, you know, your comments, both of you, 
Dr. Stern and Dr. VanLandingham, remind me that the wonderful 
thing about science is that discoveries do not occur in 
isolation, that what we learn by studying one disease can pay 
dividends in shedding light on other diseases.
    The Director of the National Institute of Mental Health, 
Dr. Tom Insel, told the HELP Committee last year that we are on 
the cusp of a revolution in brain research because of the 
incredible tools that are now available that had not been there 
before, and yet, at this critical moment, we are cutting back 
on NIH funding. Year after year, adjusted for biomedical 
inflation, NIH's budget has shrunk to the point that we are now 
investing less in research with NIH than we were in 2001.
    Let me ask the question this way. If we could double the 
budgets of your centers, what could you do and how much faster 
could you do it?
    Dr. VanLandingham. Do you want to go first?
    Dr. Stern. I will go first.
    Senator Warren. You have got to show us the aspiration 
here, Dr. Stern.
    Dr. Stern. With a doubled budget, we would not just double 
the speed at which we could answer important questions. It 
would be an exponential increase.
    Senator Warren. Yes.
    Dr. Stern. One of the things that has been happening across 
the nation has been the loss of young investigators and senior 
investigators. Young investigators, because there are no jobs 
for them, because of NIH cuts, there are no jobs for young 
post-doctoral fellows or new researchers trying to get an 
assistant professorship. Senior investigators who have been 
working for decades are having to close their labs because, for 
the first time ever, they have no funding, because of that, we 
cannot have continuity in research. We cannot have the numbers 
of people to be able to focus on a particular question at any 
given time, so, that is one of the starting points, why we 
would be able to have much faster answers is because if we had 
more money, we would be able to have a real meaningful staff to 
answer the questions.
    We would also be able to do much more with technology, and 
that is what is so wonderful about doing this type of research 
in 2014. While Senator Warren was out, I was mentioning that 
just right now, this moment, we are putting one of our former 
NFL players in a PET scanner to be able to look at tau protein 
in their brain. It is the first time we are doing it. It is 
very exciting. By being able to have support for that, to 
double our budget, to be able to continue that research, not to 
close it down, we would be able to diagnose CTE during life 
very, very accurately within the next five years.
    Senator Warren. That is amazing.
    Dr. VanLandingham.
    Dr. VanLandingham. I will start by saying that I work for 
two different nonprofit companies, for a for-profit company, 
and I am a professor at an academic institute, so there are 
various thoughts that go through my mind to answer this 
question.
    I think if we had funds from the Federal Government, let us 
say, that would sponsor private companies, that it would be 
easier for private companies to get investors. It would improve 
the value to the investor by having Federal Government support. 
That is a little out there.
    Big pharmaceutical companies do not do R&D anymore. Smaller 
companies are now the ones that have to go out there and either 
raise the money or fight for the grants just to be able to get 
this to a point where it can go into clinical trials.
    Professors in academic institutes have wonderful ideas, but 
they never, hardly ever try to commercialize them because they 
do not have the means in which to do that.
    Your question on how much money, doubling the budget, for 
$20 million, in a year, I could be in a Phase 2 clinical trial 
for concussion, a first drug. If I had $20 million today, in a 
year, I could have us in a Phase 2 clinical trial.
    Senator Warren. Okay. I appreciate it. You know, we talk a 
lot on this Committee, for example, about Alzheimer's, and the 
Alzheimer's Association says that as our nation continues to 
age, Alzheimer's disease is projected to cost our nation $1.2 
trillion a year by 2050. Over and over, we understand the 
importance of research, and ultimately, the importance, not 
just for people's lives, but the importance in terms of how 
much money we have to spend to care for people.
    I just want to make it again clear. We cannot stand by and 
do nothing. We must increase our Federal investment in medical 
research, not slash it. This is our only chance to bring costs 
in the future under control and to give people a better quality 
of life.
    Thank you very much for your work. Thank you so much for 
being here to raise awareness around this issue, and, thank 
you, Mr. Chairman, for letting us go over.
    The Chairman. Amen to your comments about research, 
Senator.
    I am going to try to squeeze us in before we have to go to 
vote, and the vote will be called momentarily, but we do not 
have to go right at that time, and I will wait until the last 
possible minute, so, let me see if I can handle quickly a 
number of questions that are still left.
    Dr. Stern, how does a TBI differ in a military combat 
injury versus a sports injury?
    Dr. Stern. The brain does not know what is hitting it. 
However, there is something new that has been occurring in the 
last 12 years in the military theaters of Iraq and Afghanistan 
and that is these roadside blast injuries that occur to our 
military servicemen and women, and, these blast injuries are 
not a direct hit to the brain or to the head, but through the 
blast waves, and often, what happens during that type of 
injury, the person not only has the effect of the blast on 
their brain and those brain cells, but the person is also 
thrown and hits their head within their vehicle, on the ground, 
et cetera.
    That is a different type of injury. That is a double dose 
on an individual who has already been exposed, perhaps, to 
similar injuries, but, just like the stories you hear of our 
football players and other athletes who want to hide their 
injuries to be able to help their team be strong, our military 
personnel do the same all too often, and, so, what we need to 
do is to be able to make sure that we reduce the repetitive 
nature of those types of injuries.
    The type of injury that one gets, let us say, in a football 
stadium is not necessarily going to be that same type of blast 
followed by hitting, but it is still going to be some kind of 
impact to those brain cells like was described earlier, the 
stretching, the shearing of those neurons that lead to this 
metabolic crisis within the nerve cells. It does not matter how 
the hit happens. That same type of change is going to occur, 
leading to the same type of acute symptoms.
    The Chairman. I want to ask Mr. Nowinski and Mr. Utecht, do 
you have any observations about player suicide?
    Mr. Utecht. Well, clearly, it is a concern, whether it is 
in wrestling or whether it is in the NFL. That is--that is the 
last thing you would ever want to see occur. I think, at this 
point, there is just not enough information to be able to say 
that they are connected, and I think that is one more thing 
that funding into research would really be able to help us to 
provide, is more context between a relationship with depression 
and traumatic brain injury, but at this point, it is not there 
yet, and, so, when we look at some of these players who have 
come to that point, it is really hard to be able to, I think, 
to make that connection yet today, between traumatic brain 
injury and suicide.
    Mr. Nowinski. Thank you for the question, Chairman Nelson. 
You know, suicide is extraordinarily complicated, but there are 
some things we do know. One is that acute concussion, acute 
traumatic brain injury does increase your risk of suicide or 
suicidal ideation within the next year, certainly, from some 
studies, and, we actually have a lot of brains in our Brain 
Bank from teenagers who have taken their lives within, some 36 
hours, some within a year, while still suffering post-
concussion symptoms, so, there is something going on there.
    Then, with long-term cases and people committing suicide 
with CTE, you know, it is hard to know if their suicide was 
linked to, maybe, anxiety or depression issues that the disease 
brought on. Certainly, what is consistent in a lot of cases is 
that it has alienated them from their families and they are not 
able to work and they become isolated. You sometimes wonder if 
the guilt and the destruction of their life had some role to 
play in the conscious decision to take their lives, but, I 
think it just shows just how much this disease does affect 
families.
    Dr. Stern. If I could add something to that, just talking 
about the science of it, suicide is a very complex, very tragic 
occurrence, but, what we do know is that the parts of the brain 
that are affected in chronic traumatic encephalopathy can, 
indeed, lead to changes in emotion and to changes in impulse 
control. Those are two of the big things that are affected by 
this disease, the amygdala, which is really the home of 
emotional regulation, and the bottom parts of the frontal 
lobes, where we control our impulses, where we stop our 
inappropriate behavior, and, if you have an individual who has 
this rage and sadness and emotional discontrol and then they 
have the inability to stop an impulse, that may lead to that 
very tragic recipe that could eventually turn to suicide.
    The Chairman. Are women more subject to this type of injury 
than men?
    Mr. Nowinski. The data would say yes. In sports like soccer 
and basketball, where the rules are very similar, women do 
suffer more concussions, and, the prevailing theory on that is 
it is likely biomechanical, the sense that they have thinner, 
less muscular necks, so their head--it takes less of an impact 
to move their head rapidly and cause their brain to move 
quickly, but, because of Title IX and because women have not 
been playing organized sports as long, we do not know what the 
long-term consequences are. We only have a handful of women--of 
female brains in our Brain Bank and we do not have a positive 
case yet of CTE, so we are not sure what we are going to see 
there, but, it is concerning.
    The Chairman. If you are the team's coach or the doctor, 
what is your best way to make an assessment as to whether or 
not your player should be able to continue?
    Dr. VanLandingham. I would say, first, you do a memory and 
attention test there on the sidelines, and nowadays, we know 
that a lot of issues after a concussion are related to balance 
impairment because of inner ear damage during the concussion, 
that a quality test for balance as well as sort of quick 
thinking, memory, attention things on the sideline is probably 
the most common thing today.
    The Chairman. Does that get into that IMPACT, the Immediate 
Post-Concussion Assessment and Cognitive Testing?
    Dr. Stern. The IMPACT test is the most common cognitive 
assessment for sideline--not really sideline testing, but for 
athletic testing. It is used most commonly as a baseline test 
before a season, and then after someone is injured, it is used 
again to compare the performance, but, it would not be used on 
the sideline. It takes too long. The environment is not 
appropriate, and, what is very important to know is that many 
of the symptoms of concussion are not immediate. They may not 
occur for hours or perhaps until the next day.
    If you are a coach trying to make a decision, first of all, 
have adequate medical staff on hand, whether that be athletic 
trainers or team doctors who are well trained in concussion 
assessment, and those medical professionals should take it very 
seriously and be independent of the coaching decisions so they 
are not pushed in any way, shape, or form to send someone back 
to play before they are ready.
    Mr. Utecht. One other thing to note on the IMPACT test, 
too, is we are finding that athletes are now failing the IMPACT 
test on purpose so that their baseline is now lower to start 
out with, so that if, in fact, a concussion occurs, they do not 
have to get back to what truly is their normal baseline, but 
one that has been fabricated because of choices they have made 
during the test taking.
    This is about changing the nature of this injury, as well, 
and really getting people to care about their brain so that 
they do not make choices like that.
    The Chairman. In this case, you mean that that enables them 
to get back out on the field.
    Mr. Utecht. Well, correct. It takes their baseline and 
lowers it so that their results do not have to come back to 
what really would be their normal baseline.
    The Chairman. I see.
    Dr. VanLandingham. They would not be taking that IMPACT 
until the day after.
    Mr. Utecht. Correct.
    Dr. VanLandingham. You are doing sort of a quick and dirty 
on the sidelines to decide whether they can go back in 
immediately or not. Then, you are holding them out and doing 
that check towards baseline the day after, and every seven days 
until they return to normal.
    The Chairman. All right. Now, there have been a number of 
athletic organizations that are getting involved in the 
business of donating millions of dollars to research, some 
through NIH. How can the public be sure that these donations do 
not buy us the outcome of the research?
    Dr. Stern. I can speak to the NIH donation by the National 
Football League. The NFL gave $30 million to the Foundation for 
NIH, which is an organization associated with the National 
Institutes of Health to accept money from the private sector to 
then be used for peer-reviewed research, and, so, there is this 
firewall between accepting the money and then the review that 
is done through NIH, not through FNIH.
    The goal of the NFL giving that money was so that it did 
not have any conflict of interest, so there was not any playing 
favorites. It was there to be able to truly support research so 
it can be peer-reviewed and funded just like any other NIH 
research, so, in that case, I strongly support it.
    The Chairman. Okay. Now, final question. A recent medical 
journal said emergency room visits for these sports-related 
TBIs have increased by 92 percent over a ten-year period. You 
are a parent. You have a child. They want to play sports. If it 
is a contact sport, do you let them play? Let us just go right 
down, right down. Mr. Nowinski.
    Mr. Nowinski. Sure. You know, after doing this for a long 
time----
    The Chairman. I am going to keep you short----
    Mr. Nowinski. All right.
    The Chairman. [continuing]. Because we have got to go vote.
    Mr. Nowinski. Yes. I am saying, definitely no contact 
sports with repetitive brain trauma before high school, and 
then after that, you know, I have time, I do not have kids yet, 
so we will see, but, I think, I would say, do not let them get 
hit in the head hundreds of times a year before high school.
    Mr. Utecht. I would have to agree with Mr. Nowinski. In 
fact, there is a high school in Texas who has now gone to 
pretty much flag football up until high school, and, really, 
you see even players in the NFL who did not play football in 
college. They were basketball players, but they have become Pro 
Bowl players in the NFL, so, can you, in fact, remove contact 
sports until high school and still teach fundamentals, still 
teach even correctly how to tackle but removing the contact? I 
really believe that you can.
    The Chairman. Doctor?
    Dr. VanLandingham. I agree. I just--I still have my 
concerns about as large and as fast as high school players have 
gotten today, that there still will be a major issue, but, at 
least we have removed anybody under the age of 15 or 16 from 
being engaged in it.
    The Chairman. Dr. Stern.
    Dr. Stern. I think we have had a tremendous knee-jerk 
response in our society to limited research that has led to a 
lot of, perhaps, scary stories that are passed along, and that 
is before we have adequate science. However, we also have to 
think rationally and make rational decisions. I think people 
are now understanding that hitting your head over and over 
again is not necessarily a good thing for you, so, I would 
agree with everyone else that, at the very least, contact 
sports with repetitive hits to the head should be limited to as 
late as possible.
    The Chairman. We especially want to thank our special 
guest, Kevin. We want to thank all of you----
    Senator Blumenthal. Mr. Chairman----
    The Chairman. [continuing]. Most illuminating.
    Senator.
    Senator Blumenthal. I apologize for interrupting, but I am 
wondering whether the record could be kept open. This has been 
such a phenomenally----
    The Chairman. Absolutely.
    Senator Blumenthal. [continuing]. Good panel. I have some 
additional questions I would like to submit.
    The Chairman. The record will be kept open for five days.
    Senator Blumenthal. Thank you.
    The Chairman. The meeting is adjourned.
    [Whereupon, at 2:41 p.m., the Committee was adjourned.]

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                                APPENDIX

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                      Prepared Witness Statements

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    Prepared Statement of Christopher Nowinski, Founding Executive 
                   Director, Sports Legacy Institute

Introduction

    Chairman Nelson, Ranking Member Collins, and Members of the 
Committee, thank you for inviting me to speak today before the 
Committee. My name is Chris Nowinski, and I am the founding 
executive director of the Sports Legacy Institute, known as 
SLI, which is a non-profit organization dedicated to solving 
the sports concussion crisis through education, advocacy, 
policy, and research. I am also a co-founder of the Boston 
University Chronic Traumatic Encephalopathy (CTE) Center and 
serve on the executive committee of the Boston University 
School of Medicine Alzheimer's Disease Center, which houses the 
CTE Center.
    I serve as a volunteer advisor to the National Football 
League Players Association, Major League Lacrosse, and The Ivy 
League. I also have a personal relationship with concussion, 
and tremendous concerns that I have increased my risk of 
developing a degenerative brain disease in the future. It is my 
hope that this hearing raises awareness of the urgent need for 
funding for research on traumatic brain injuries, as well as 
the tremendous opportunities we have for prevention of their 
long-term consequences.
    I never had a second thought about concussions or brain 
injuries until one day when my world changed so drastically 
that I would never go a day without thinking about my brain 
again. It happened late in my competitive athletic life--I was 
24 years old. After playing contact sports in high school and 
at Harvard University, I had become a professional wrestler, 
known as a Superstar, with WWE. I got to travel the world 
playing a bad guy, or ``heel,'' known as Chris Harvard who 
creatively insulted the fans' intelligence and cheated to win. 
Let me remind you that this was a character than I played; it 
was a performance to entertain our fans, and it was fun.
    In a match at the Hartford Civic Center, I was kicked in 
the head by my opponent Bubba Ray, and my world immediately 
changed--my head began throbbing, everything got foggy, and 
most importantly, I forgot the script. I couldn't remember how 
we were supposed to finish the match. It was terrifying.
    We created a new finish, and on my way back to the locker 
room I was stopped by our athletic trainer, who asked if I was 
alright. By that time, my memory had begun to come back, so I 
answered instinctually with, ``I'm fine.'' But I wasn't--I went 
down a hallway and lay down on the ground, holding my head as 
if I was trying to keep my brain from falling out.
    The symptoms, which expanded beyond daily headaches to 
include depression and sleepwalking, would not go away. I 
traveled from doctor to doctor until I met Dr. Robert Cantu, my 
cofounder at SLI. He was the first person to ask me ``How many 
concussions have you had?'' I told him, ``One.''
    Dr. Cantu was the first to then ask, ``How many times have 
you been hit in the head and become confused, dazed, or 
considered yourself `dinged?' I said ``Doc, that happens all 
the time.'' I had been playing contact sports my entire life. I 
played soccer from age five to thirteen. I played football from 
age 13 to 21. I wrestled for three years. I probably suffered 
over 10,000 blows to the head, and at this point I can remember 
nine concussions since the age of 19, but can't remember what 
happened prior because I never knew the dings were worth 
remembering.
    Dr. Cantu went on to tell me, ``The symptoms you are 
experiencing are likely the result of cumulative trauma. In 
addition, the fact that you never took a day off for those 
injuries means that each one was more damaging than it needed 
to be. Had you chosen to rest, you would have probably 
recovered by now.''
    There I was, at 24, learning for the first time how fragile 
my brain was, and how critical rest is after a concussion. I 
wish I would have recognized my concussions, reported them to a 
medical professional, and then rested both physically and 
cognitively. My ignorance cost me--a career, five years of 
health before the daily symptoms went away, and who knows what 
else in the future. Dr. Cantu shared with me his concerns about 
the risk of progressive brain degeneration that may manifest 
mood disorders, behavioral problems, cognitive impairment and 
memory deficits, and eventually dementia. All this from a 
couple of head knocks that seemed perfectly innocent at the 
time.

The Long-Term Effects of Brain Trauma

    Scientists have been writing for nearly 100 years that 
brain trauma can lead to a degenerative process in the brain, 
but it has only been in the last seven years that we have had a 
focused national conversation on the problem.
    Of concern is the growing evidence that brain degeneration 
continues after the injury without any additional trauma--the 
brain essentially continues to rot away. The disease we are 
most concerned with is Chronic Traumatic Encephalopathy (CTE), 
which Dr. Ann McKee, Professor of Neurology and Pathology at 
Boston University School of Medicine and Director of 
Neuropathology Service for the New England Veterans 
Administration Medical Centers, has now discovered in over 100 
former contact sport athletes and military veterans at our VA-
BU-SLI Brain Bank. Studying brains post-mortem is currently the 
only way to diagnose CTE, which also means we don't know how 
many people have it. Unfortunately, 58 of the first 62 donated 
brains of professional football players that we examined ended 
up having it, and we have found the beginnings of the disease 
in football players as young as 17.
    My colleague Robert Stern, PhD, Professor of Neurology and 
Neurosurgery at Boston University School of Medicine, has 
submitted testimony on the science behind CTE and brain 
degeneration, so I will focus my remaining testimony on the 
ethical and policy implications of the work.

Moving Forward

    What the scientific evidence appears to be telling us at 
this point is that the human brain, while magnificent and 
resilient, is particularly vulnerable to brain trauma. The 
working theory is that too much brain trauma, in the form of a 
severe injury or repetitive mild injury, can spark disease.
    What is special about this brain disease is that we think 
we know the primary cause--concussive or subconcussive brain 
trauma. In fact, no one has ever been diagnosed with CTE who 
wasn't exposed to significant brain trauma. Therefore, unlike 
Alzheimer's disease, Parkinson's, or many other 
neurodegenerative disorders--we may be able to effectively 
prevent CTE by limiting or eliminating exposure to brain 
trauma.
    While the majority of CTE cases have been found in 
professional athletes, it has also been found in many athletes 
that never played beyond high school, and only played sports as 
minors. Through participation in sports, we are giving some 
children a preventable degenerative brain disease
    We must act to recognize and minimize this risk. This is 
not a war on football, this is not a war on sports, but it is a 
war on brain injury.
    There are a number of meaningful policy solutions that are 
slowly being implemented across sports, including:

    1.  Education, so that athletes, parents, coaches, and 
medical professionals can accurately recognize and respond to 
concussions.
    2.  Better tests and return-to-play protocols, so that 
athletes can recover before being exposed to another injury.
    3.  Better equipment, so that plastics, rubber, and foam 
can help absorb impact and draw it away from the brain.

    It has been rewarding to watch WWE embrace brain trauma 
research and implement innovative concussion management, 
education, and prevention programs. In recent years, WWE has 
banned certain moves added full-time doctors to tour with 
talent, added computerized baseline testing, and annual 
seminars for all talent, referees, producers and medical 
personnel on concussions. In fact, I travel to the WWE 
Performance Center in Orlando where they train new recruits and 
conduct an educational seminar for all new hires on concussions 
before they step foot into the ring, emphasizing the urgency of 
preventing concussions along with the health and career 
advantages of reporting them. WWE is also one of the largest 
corporate donors to CTE research.
    However, as we implement these changes, they expose the 
gaps that we may never be able to close, and that call into 
question how effective our policy changes will be in changing 
outcomes for athletes, including:

    1.  Current education for athletes does not appear to be 
effective. While we change their knowledge of concussion signs 
and symptoms, we still struggle to convince them to report 
their injuries.\1\
---------------------------------------------------------------------------
    \1\ Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA 
concussion education in ice hockey: an ineffective mandate. BJSM. 2013 
Aug 20.
---------------------------------------------------------------------------
    2.  We may not be able to educate the youngest athletes, 
pre-high school, to even recognize the signs and symptoms of 
concussion enough to report when they are injured.
    3.  We still do not have a biomarker for concussion, and 
have imperfect ways of determining when an athlete is injured, 
or when it is safe to return. Children are more vulnerable: 
widely used return-to-play tests for adults and teenagers 
simply do not work for children.
    4.  Adding doctors and athletic trainers to the sideline 
dramatically improves the odds of recognizing a concussion, yet 
only about half of high schools have an athletic trainer, and 
they are rarely available prior to high school. Without them, 
likely 85 percent-95 percent of concussions go undiagnosed.\2\
---------------------------------------------------------------------------
    \2\ Echlin PS, Johnson AM, Riverin S, et al. A prospective study of 
concussion education in two junior ice hockey teams: implications for 
sports concussion education. Neurosurg Focus 2010;29:E6.
---------------------------------------------------------------------------
    5.  Young athletes have biomechanical and developmental 
differences that make them more vulnerable to concussions and 
their negative consequences.

    Most of these gaps are not ever going to be closed 
directly--we will never have a doctor on the sideline of every 
athletic event, and we will never be able to teach every child 
how to recognize when they have a concussion and report it to 
their parent. While we wait for technology to close those gaps, 
the best solution is prevention, and prevention is far too 
often missing from this discussion.
    The little research we have indicates that people at 
greater risk for trauma-linked brain disease start younger, 
play longer, and receive greater cumulative brain trauma 
(concussions plus subconcussive impacts).
    We can reduce cumulative brain trauma, and some sports are 
working to decrease the frequency of brain trauma. Indeed, SLI 
has developed the Hit Count Program which is designed to use 
sensors to create a Pitch Count for the brain, and eventually 
provide guidelines and limits.
    However, the one option we have the most control over is 
when athletes start receiving repetitive, voluntary brain 
trauma. This does not refer to accidental, rare brain trauma, 
the kind that can occur when someone trips and falls. It refers 
to regular, unavoidable brain trauma, the kind that occurs when 
a football player makes a tackle or block, or purposeful, 
repetitive brain trauma, like heading a soccer ball.
    The curious thing about repetitive brain trauma in sports 
is that most people don't think it is a good idea to hit a 
child in the head. In our culture and in our legal system, 
outside of the context of sports, it is considered abuse. Deep 
down, we know there is something inherently disconcerting about 
children being hit in the head, and the science is now finally 
catching up and putting numbers where before there was only 
intuition.
    I don't believe we should continue to tolerate repetitive 
brain trauma in sports for children. Children should play games 
for fun, exercise, and life lessons. They should not just be 
playing the sports that professionals play, which we watch on 
television for entertainment and that are organized for profit.
    Some governing bodies of youth sports have taken notice of 
the long-term risks of brain trauma and made logical changes. 
USA Hockey raised the age of the introduction of checking from 
11 to 13, in part to reduce the number of concussions, and US 
Lacrosse continues to change its rules and penalties to 
eliminate all purposeful hits to the head for youth.
    But not every sport is reacting quickly. Current guidelines 
in soccer which are not well enforced, recommend introducing 
headers at age 10. This week, SLI is teaming up with the Santa 
Clara Institute of Sports Law and Ethics (ISLE) on a campaign 
to educate parents and coaches on the risks of headers in 
soccer prior to the high school level.
    Former US Women's National Team player and ISLE board 
member Brandi Chastain and former teammates Cindy Parlow Cone 
and Joy Fawcett are leading the campaign along with SLI medical 
director and concussion expert Dr. Robert Cantu, to educate 
parents and coaches that the risks of introducing heading prior 
to high school have to be weighed against the rewards of more 
skilled heading among children.
    Chastain, Parlow Cone, and Fawcett, former professionals 
who are now parents and coaches, don't allow their children or 
players they coach to head the ball before high school, as they 
don't believe the risk is worth it. I hope the rest of the 
world follows their lead.
    In many ways, the risks involved with brain trauma mimics 
smoking cigarettes. The more cigarettes one smokes, the greater 
the risk of lung disease. As a society, we determined that no 
child should smoke before age 18, when they have the capacity 
to understand the long-term risks involved, and we have immense 
campaigns to discourage children from smoking.
    We should view purposeful brain trauma in children in a 
similar fashion, as both lung disease and brain disease are 
expensive problems to care for down the road, and will 
negatively impact our health care system and our economy.

Conclusion

    We must not underestimate the long-term impact of brain 
injuries. With one in four boys and one in 16 girls in America 
playing contact sports, we are putting a lot of children at 
risk for CTE. We owe them, as well as our military veterans, 
greater investment into finding ways to effectively minimize 
the negative consequences of inevitable brain trauma.
    We must also take what we have learned about brain injury 
and take advantage of opportunities we have to prevent brain 
trauma and prevent CTE, and it begins with changing the culture 
of sports. I look forward to working with you to protect those 
at risk.

       Prepared Statement of Ben Utecht, Former National Football

      League Tight End, Cincinnati Bengals and Indianapolis Colts

Concussed

    ``I'm in here counting the days while my mind is slipping 
away. I'll hold on as long as I can to you. I may not remember 
your names or the smell of the cool summer rain, everything and 
nothing has changed, nothing has changed.''--Ben Utecht

    I remember my first tackle vividly: digging the toe of my 
foot into the soft grass, giving my young athletic body the 
best chance for speed that it had. With complete abandonment, I 
took off toward my target and threw myself into the chest of my 
dad, who enveloped me in his arms as he was falling backwards 
onto the ground from his knees. Playing catch in the backyard 
with dad in 3d grade is when it all began. Then came the pads 
in 4th grade along with full contact nine-year-old aggression. 
When I look back at my complete experience in tackle football 
from nine years to twenty-nine years of age, I am shocked to 
say that I had a twenty-year career playing the game of 
football. What a career it was . . .
    The night was February 4th of 2007. There was a cool Miami 
Florida mist filling the Dolphins stadium as I stepped on to 
the largest professional sports field in the world on that 
night. It was hard to believe that a river rat kid from 
Hastings, MN was now one of the starting tight ends in the 
biggest game in history. Roughly 100 million viewers tuned in 
that night from around the world to watch Super Bowl XLI, the 
Indianapolis Colts vs. the Chicago Bears. I'll never forget two 
weeks prior when our Pro-Bowl place kicker, who had already won 
three Super Bowl rings, told the team ``don't blink, don't you 
dare blink'' at kick-off, so there I was standing between 
future Hall of Fame head coach Tony Dungy and future Hall of 
Fame quarterback Peyton Manning watching our kicker about to 
lay his foot into the sweet spot on that NFL pig skin ball, 
when I remembered his words. The whistle blew and the players 
let loose their speed and our kicker crushed the ball. I kept 
my eyes as wide open as humanly possible and experienced a 
light show I'm sure would rival that of Neil Armstrong's. It 
was truly amazing, as if I was dancing with the stars. It was a 
very special cinematic slow motion picture moment that I hope 
is never taken from me. We went on to defeat Chicago 29?17, and 
the Indianapolis Colts became world champions. It was my dream 
come true.
    That dream was shattered two years later when I woke up 
face down on a training camp field in Georgetown Kentucky, 
playing for the Cincinnati Bengals. Next I was strapped down to 
a gurney and rushed to the hospital after my 5th documented 
concussion. That began an 8-month rehabilitation processes that 
led to my retirement from the NFL due to traumatic brain 
injury. My post concussion symptoms were numerous, including 
amnesia, sleeplessness, night sweats, dizziness, fatigue, and 
some behavioral changes, to name several. However it was a gift 
I took for granted that would become my greatest concern and 
priority . . . My memory.
    My memories began to fade away along with pieces of my 
identity. My wife Karyn and I, along with our three beautiful 
daughters, visited one of my best friends and roommates from 
college. Matt and Kim began sharing favorite moments from their 
wedding as Karyn nodded in remembrance while I sat in mental 
darkness trying to understand why nothing sounded familiar. I 
stopped Matt mid-sentence, asking him, ``Why wasn't I able to 
be at your wedding?'' He looked at me awkwardly and continued, 
but again I asked the same question. This time Matt, Kim and 
Karyn stopped talking and studied me looking for a comedic 
reaction, but nothing came. I continued, ``When was it . surely 
I wasn't busy?'' Kim got up from the table and retrieved their 
wedding photo album. Page after page--I was in disbelief, 
seeing myself in numerous pictures, as a groomsman and singing 
for them a song. To this day I still have no memory of that 
event. Unfortunately for my family and me, that is only one of 
multiple memory gaps in my 32-year-old brain.
    What is my greatest fear? It's to be trapped inside the 
coffin of my mind. To wake up one morning and not remember the 
faces and names of the people I cherish the most. I was asked 
by a good friend to do something very difficult. Write a love 
letter to my wife and girls from the perspective of the 50-
year-old NFL'er who doesn't remember them any more. I wrote the 
letter, on a plane ride home with the brim of my hat over my 
eyes to hide the tears as they began to flow. This letter 
produced the song that will forever let my wife and three 
beautiful girls know that no matter what brain disease may take 
from me in the future, it can never take their love.

    ``I can still feel you here in this place beyond all tears, 
where love does what it does, it stay, yes it stays, and I will 
remember your smiles and your laughter long ever after this 
moment is gone . . . Seasons turned and turned again, till they 
became remember when. The love in your hearts made this man 
complete, my Cinderella's you danced on my feet. You will 
always be my girls, you're the beauty of my world and no matter 
how tomorrow unfurls, till the moment I am dome with this 
world, my yesterday babies in curls. You will always be my 
girls''--You Will Always Be My Girls, Ben Utecht/Rick Barron

    I can't help but to throw myself into a new target . . . 
Neurology. To tackle a new opponent, brain disease, and 
particularly TBI/Concussions. I have been impassioned through 
advocacy to fight for those lives being ripped apart by brain 
diseases and disorders. We need a national revival for funding 
research that will help us find the cures. You as Senators can 
become my new coaches: you can help decide the games strategy 
and put in the countless hours of work and research into 
creating policies that can change this nation connecting people 
to their most valuable asset, their minds. We can become world 
champions on a new gridiron, the field of our identity. I will 
not stop in the pursuit of finding cures for brain disease, and 
creating an emotional connection between the world and 
neurology because neurology is what cradles the miracle that 
makes us human, our brains. It's time for all of us to realize 
how special our brains really are!

Concussion Insurance Policy Proposal

    I urge Congress to mandate that the NFL and any other tax 
exempt non-profit sports organization, who are making millions 
and billions of dollars off of athletes sacrificing their brain 
health, to pay premiums on a long-term health care and 
disability insurance policy specifically surrounding Traumatic 
Brain Injury and Concussions. One solution to the concussion 
crisis, which has now impacted the entire globe athletically 
and beyond, is to provide a security blanket that can cover the 
future brain health of our athletes. You must see clearly that 
you cannot have professional contact sports without traumatic 
brain injuries. Therefore athlete's brains should be covered 
under a Concussion Policy.

Keys to Success

    A mandate that makes all of the billionaire owners, 
franchises, and Professional sports organizations invest in the 
future brain health of their players.
    Traumatic Brain Injury and Concussions are an epidemic that 
effects the entire population, which means this insurance 
policy could also be made available for the general population 
specifically our youth in contact sports who are injuring their 
brains during the most important developmental stages of their 
brain maturation.
    Underwriting will be essential to the success of the 
policies.
    The insurance policy could also provide annual Neurologist 
consultations or physicals that would allow all athletes and 
general population under the policy to start a relationship 
with a brain expert who can best diagnose and manage a TBI/
Concussions. This annual physical would be most important to 
the management and care of our youth who are active in contact 
sports.
    These policies would also provide accountability by 
battling the issue of athletes withholding critical information 
regarding a TBI/Concussion they have sustained. Athletes lie 
about symptoms in part because they lack job security. A 
concussion policy would provide them with future financial 
security regarding their brains.
    The Premiums should be made tax deductible.

      Written Testimony of Jacob W. VanLandingham, Ph.D., Director

          of Neurobiological Research at Tallahassee Memorial

       Healthcare Neuroscience Center, Assistant Professor in the

           Department of Biomedical Sciences at Florida State

      University College of Medicine, and Founder and President of

              Prevacus Incorporated, Tallahassee, Florida

    Mr. Chairman and Members of the Committee, thank you for 
the opportunity to appear before you today to discuss the 
current State and future needs for improving the treatment and 
management of mild traumatic brain injury.

Background

    According to the most recent statistical data from the 
Center for Disease Control and Prevention (CDC), approximately 
1.6 to 3.8 million people experience a traumatic brain injury 
(TBI) in the United States each year alone, resulting in 52,000 
deaths. TBI was the leading cause of combat deaths in both 
Operation Iraqi Freedom and Operation Enduring Freedom; 
estimates range from 15 percent to 25 percent of all injuries 
sustained in warfare during the previous century involved TBI. 
Of significant concern for this Committee, pediatric patients 
struggle more than any other age group to return to function 
after a brain injury. Most relevant to this hearing: over 50 
percent of deaths associated with falling in the elderly are 
due to TBI. Although interest in severe TBI has long dominated 
research studies, we now know the number of TBIs of mild to 
moderate severity far outnumber those with severe injury. In 
fact, annually it is now known that more than 1.7 million 
people are treated and released from emergency departments. 
Recent evidence suggests that participation in sports involving 
contact and/or collisions may alter regional brain metabolic 
processes and increase the risk of catastrophic 
neurodegenerative diseases, including chronic traumatic 
encephalopathy (CTE) which has been linked to repetitive 
concussion brain injuries. Over 300,000 sports injuries a year 
have a brain injury component. When considering the burden of 
TBI on our healthcare system consider that in the US each year 
over 70 billion dollars are spent from lost work days to 
intensive care units.

Health-Consequences-of-Concussion

    Contact sports are synonymous with mild TBI (mTBI), which 
is also known as concussion. As the brain accelerates and 
subsequently decelerates inside the skull its sensitive 
processes are stretched and damaged. Additionally, bruising 
presents at sites where high speed impact occurs against the 
inner skull. Returning to play too soon after a concussion 
increases the risk of experiencing another more serious TBI 
that can be caused by less force. Not to mention, those 
athletes who have experienced more than two concussions are at 
higher risk for permanent to prolonged symptomology. Recent 
findings supported by the NIH have shown that repetitive 
concussions may lead to progressive decline in brain functions 
over the life span. It is becoming more evident that athletes 
who have sustained multiple concussions are at risk for 
clinical depression and subsequent suicidal ideation. These 
athletes also tend to have memory and attention impairment with 
delayed information processing speed. Some reports State that 
of all the people engaged in athletics 19 percent may suffer a 
concussion each year. Individuals who experience concussions 
have up to a 20 percent likelihood of developing Post-
Concussion Syndrome (PCS). Unlike the concussed who return to 
normal within two weeks, patients with PCS have long term 
disability with prolonged symptoms including: chronic 
headaches, fatigue, sleep difficulties, personality changes, 
sensitivity to light or noise, dizziness when standing quickly, 
and decreases in short-term memory, problem solving and general 
academic functioning. Clearly, anyone who has sustained a 
concussion needs to be immediately evaluated and treated by a 
physician, and closely monitored thereafter. Also, the 
individual should visit and be evaluated by a 
neuropsychologist, a specialist who can best monitor the 
athlete's symptoms and immediately put appropriate treatments 
in to play.

Mild-Concussion-Defined; Challenges-With-Diagnosis

    A mild concussion, is characterized by a confused or 
disoriented State lasting less than 24 hours; loss of 
consciousness for up to thirty minutes; memory loss lasting 
less than 24 hours; and structural brain imaging (CT scan) that 
yields normal results. Concussions are notoriously difficult to 
diagnose and treat. Each injury may have a different 
constellation of findings, and such findings can often be very 
subtle in their presentation as well as intentionally masked by 
the patient. Current sideline tests have multiple limitations, 
including low sensitivity, environmental factors, ease of 
implementation and equipment restrictions. Furthermore, return 
to sports participation, work, and military duty criteria are 
based on symptomatic resolution and normalization of 
neurocognitive function. With the former, reliance on the 
patient's report is required, and patients will frequently do 
whatever it takes to get back to their prior activities, 
including the use of deception. With the latter, baseline 
testing is needed for comparison, and many individuals will 
attempt to ``sandbag'' their baseline in order to be able to 
more easily pass the test. This is to say, just as you would 
expect a young athlete or soldier to do what it takes to return 
to the field, the elderly also tend to do what it takes to 
preserve independence.
    Finally, many technologies used for concussion diagnosis 
and clinical assessment have different limitations; including 
technically difficult application, diagnosis-only (i.e. 
inability to inform return-to-play decisionmaking), poor 
sensitivity, and high costs.

A Compounding Injury

    As a compounding injury, a significant consequence of not 
properly treating mTBI is that suffering one injury makes a 
second more likely; and the second injury will most likely be 
worse than that first; and so on and so forth. Chronic 
traumatic encephalopathy (CTE), a form of neurodegenerative 
disease, has been recently shown to be associated with 
repetitive concussions. CTE is characterized by a progressive 
taupathy, neuritic threads and neuronal TAR DNA-binding 
protein-43 (TDP-43) proteinopathy. Tau protein aggregation and 
formation of neurofibrillary tangles is also associated with 
the loss of control of mood, emotions, and intellectual 
functioning. The pathological hallmarks of CTE have been 
recently discovered in the brains of professional athletes who 
suffered repetitive TBI and in brain tissue from deceased 
combat veterans diagnosed with psychological disorders such as 
PTSD and manic depression. In fact, it is now widely recognized 
that the behavioral sequeale of CTE can mimic Alzheimer's 
disease (AD) and Frontotemporal Dementia (FTD), including 
memory loss and depression. The severity of AD has been 
associated with abnormal hyper-phosphorylated tau containing 
aggregates of TDP-43. Repetitive TBI with the development of 
CTE leads to abnormal TDP-43 expression in about 83 percent of 
cases. Thus, it is imperative to develop a therapeutic 
intervention which can block the cellular and molecular 
cascades following TBI that lead to tau misfolding and 
aggregates, NFT formation and tau proteinopathy. The recent 
elucidation that NFT is made of tau and amyloid fibers should 
make it possible to select specific drugs and molecules that 
may stop or prevent the process from progressing, rather than 
simply suppressing the symptoms. That is to say, simply, 
concussion may not have to be a compounding injury at all. The 
findings of tau and TDP-43 are not only linked to CTE but also 
to Anterior Lateral Sclerosis (ALS). ALS is a degeneration of 
the motor portions of the spinal cord that allow for voluntary 
muscle activity. Recently, autopsied victims of brain trauma 
also diagnosed with ALS have shown that these pathological 
markers are not only in the brain but have diffused into the 
spinal cord.

The Aging Veteran Community

    Commonly referred to as a signature wound of the last 12 
years of sustained combat in Iraq and Afghanistan, TBI remains 
number one on the Combatant Command (COCOM) medical priority 
guides because of the impact on readiness and combat 
effectiveness, as well as the long term effect on service 
members' health and quality of life. According to Defense 
Medical Surveillance System (DMSS), Defense and Veterans Brain 
Injury Center, of the total 253,330 reported traumatic brain 
injury (TBI) cases between January 1, 2000, and August 20, 
2012, 194,561 have been mild. As with other populations, 
combat-related brain injuries can result in serious 
neurological and psychological disorders, such as memory 
impairment and suicidal ideation. Additionally, and perhaps 
unique to the military and veteran community, concussion can 
amplify PTSD behaviors. Given the seriousness of this injury on 
both military readiness and the aging veteran population, as 
well as the translation of any findings to the overall civilian 
population, the Department of Defense and Department of 
Veterans Affairs are collaborating on concussion research. The 
majority of their research funding and effort, however, has 
been spent on diagnosis and prevention, rather than treatment. 
Given the compounding nature of concussion, as well as the 
enormous cost of treating our already aging veteran population, 
in my professional opinion more emphasis must be placed on 
developing treatments. There are, however, bright spots. The 
Army's Medical Research Material Command (MRMC) is working to 
fund research on treatments; the Combat Casualty Care 
Directorate has a staff that is attuned to their mission of 
treating combat injuries and, when possible, returning soldiers 
to the battlefield. Dr. James Kelly, Executive Director of the 
National Intrepid Center of Excellence, is also leading the way 
in efforts to treat our Wounded Warriors. The work that both of 
these organizations are doing right now, I believe, will yield 
positive results that will translate to the civilian population 
just as other areas of military research have ultimately done 
so. Given the translational nature of this research, this 
Committee, the Committee on Veterans Affairs, the Armed 
Services Committee and the HELP Committee should continue to 
emphasize, across Committee jurisdictions, the importance of 
the effort to find a treatment for concussion.

Kids and Concussion; the Unknowns

    By midnight tonight, nearly thirty children in the U.S. 
will have died from head injuries incurred today and many more 
will develop lifelong disability from their TBI. Even more will 
exhibit at least transient impairment of learning, development, 
and behavior. Although head injury is the leading cause of 
death and disability in children, there are only general 
management guidelines, and no Class I evidence supporting any 
standard therapy. While only a modest number of pediatric 
clinical trials for traumatic brain injury (TBI) have been 
conducted, nearly all pediatric trials and over 100 adult TBI 
trials have failed to show significant neuroprotective benefits 
of any specific therapy. More attention to the potential risks 
associated with TBI in the developing brain is needed to 
develop proper management and treatment strategies. While we do 
not fully understand the vulnerability of a child exposed to 
repeated TBIs in sports and household settings, we do recognize 
that this population struggles even more than the adult 
population to recover from a single TBI, because the brain is 
not fully developed until people are in their early 20's, the 
risk for serious brain injury is greater for those athletes who 
are younger than 25. The risk may be particularly great for 
high school athletes because they are big and strong enough to 
hit each other with tremendous force, but their brains are 
certainly not mature. Therefore, dangers in the near and long 
term are clearly highest in a younger population of athletes.

Brain Injury in the Elderly; Dramatic Increases With Prolonged Life 
        Span

    In the opinion of the World Health Organization, TBI will 
surpass many diseases as the major cause of death and 
disability by the year 2020. Approximately 10 million people 
worldwide are affected by TBI per year. Often neglected, 
elderly TBI patients are going to be an increasing financial 
burden to the society as our population continues to age. The 
CDC has identified concussion as a silent epidemic and the 
elderly portion of this diagnosis the silent population. Falls 
are the leading cause of TBI in the elderly. Following a TBI an 
elderly person has much more trouble returning to normal. The 
aged brain is not equipped to recover from trauma like more 
youthful adult brains. Additionally, the elderly have a much 
harder time recovering when left non-ambulatory and from 
avoidance of other transmittable conditions associated with 
trauma as their immune system is weaker with age. Often 
following a TBI an elderly patient will be transferred directly 
to long term housing. Many of the elderly are on blood thinners 
for other conditions and therefore more likely to acquire a 
hematoma with increased intracranial pressure following a blow 
to the head. The CDC has made a strong effort to educate 
caregivers on how to reduce falls in the elderly however 
studies are still needed to determine specific treatment and 
management strategies for the elderly who have sustained a TBI 
which tends to present differently than in younger adults.

Research Methods

    Recent workshops of the TBI and stroke scientific 
communities have examined why agents with preclinical 
therapeutic efficacy have failed to translate to clinical 
success. In addition to challenges imposed by the heterogeneity 
of TBI and differences between rodents and humans, they 
concluded agents should be tested in multiple animal models, 
using clinically relevant outcomes, short-term and long-term 
endpoints, and histological and functional metrics, because of 
marked differences in maturation, morphology, and injury 
mechanisms, current and popular rodent TBI preclinical therapy 
trials must be complemented by additional preclinical trials. 
Pig models are highly developed and currently should be 
considered the top choice. Research is needed to develop time-
courses and mechanisms associated with focal and diffuse 
injuries that will identify time intervals and targets for 
future clinical care to develop management and treatment 
strategies. Further research is needed to develop clinically 
relevant imaging and neurointensive care monitoring methods in 
animal models.

Conclusions

    Concussions and other forms of TBI will no longer be a 
silent epidemic as we continue to shine light on the negative 
effects of the disorder. TBI transcends generations and 
populations from the infant to the elderly and from athletic 
fields to battlefields. In our fast-paced and too often violent 
world it is no surprise that head injuries are becoming all too 
common. The current cost to society to care for TBI patients is 
over 70 billion dollars per year in the US alone. From lost 
work for the victim as well as their family members to surgical 
procedures to reduce pressure on the brain, the consequences of 
TBI are catastrophic to so many involved. Research to date has 
focused on identifying the pathology of the injury and 
diagnosing based on individual presentation. Further funding 
has gone to prevention to try and improve protective gear and 
educate caregivers/coaches/commanders on removing risks. 
Unfortunately, no funding has focused on developing new 
treatments from a pharmaceutical or rehabilitation perspective. 
As many more parents are keeping their kids out of sports these 
days due to fear of concussion this may lead to other disorders 
such as obesity and juvenile diabetes as a result of lack of 
activity. Furthermore, no one wants to see rule changes to our 
favorite past times which reduce the excitement of the games. 
Even more disturbing for the safety of our country would be a 
reduction in armed forces enrollment.
    In my professional opinion we are dealing with two major 
issues that need our complete focus and this focus requires 
research and development funding and collaboration. First, 
concussions are compounding. In other words, if you have one 
you are more likely to have two and they become additive when 
it comes to pathological findings and subsequent negative 
presentation. Therefore we need to develop new acute 
pharmaceutical treatments that are delivered immediately after 
the concussion to prevent the compounding nature of subsequent 
concussions. By developing new rehabilitative techniques they 
can be used as an adjunct to these drug treatments. Second, we 
have a population that currently has or is predisposed by 
multiple prior concussions to AD and ALS-like pathologies. 
Therefore we need to develop new chronic pharmaceutical 
treatments that can block the progression of these pathologies 
and stop the disease process in its path.
    Prevacus Incorporated is positioned today to develop a 
pharmaceutical for the acute treatment of concussion and 
prevent the compounding effects of brain trauma. Designed as a 
nasal inhalant the drug will be readily available in the field 
for use by athletic trainers, medics and ambulance technicians. 
The lead candidate is a neurosteroid and in toxicology studies. 
Clinical trials are designed to start in January, 2015 if 
sufficient funding is acquired. We have also designed 22 other 
neurosteroids and are poised to start preclinical studies with 
two of them this summer in animal models of AD and ALS. Now is 
the time for leaders in science, medicine and government to 
come together to advance new treatments for concussion and halt 
the progression of others who are already facing the TBI-
associated pathology.

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