[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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via internet: http://www.govinfo.gov
______
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
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Kim Lipsky, Majority Staff Director
Priscilla Hanley, Minority Staff Director
C O N T E N T S
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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
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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
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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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