$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 statement in the record. and part of what we're 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 flow -- the normal function of the brain. more mild tbi's, 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 they're suffering from memory loss and other impairments caused by repeated blows to the head. and, of course, we are seeing the tbi's that are coming home from overseas with our men and women in uniform, and 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 tbi's, and they say that they occur in the u.s. each year. such head injuries are not limited obviously to just one sport. they occur in a wide range of sports, and most recently reminded of that in the story from "the new york times" with a 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 risks 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. and these initiatives involve a number of organizations. so while we are making progress, it's important to note that much more research is needed. and to see all of the links to other things such as alzheimer alzheimer's. and so today we're going to hear from to former professional athletes who had their careers cut short due to concussions, and now they're going to wonder about their function in the future. going to take testimony from two prominent medical researchers who will discuss the latest research. and i'm going to give that privilege of introduction to senator warren after i turn to our great 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 associate 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 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 neurologic diseases like alzheimer's later in life, there is increasing evidence of a relationship. women even more than men may be more likely to experience long-term symptoms, such as cognitive and visual impairments, after sustaining a serious head injury. we know that currently, almost two-thirds of americans living with alzheimer's disease 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 diagnosis through better imaging technologies, and also improve 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 that there is a 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. with a great panel of witnesses, and i look forward to getting their insights in learning more about the current research on this topic. >> thank you, senator collins. i want to specially recognize kevin turner. kevin was a star fullback at the university of alabama. he played eight seasons with the new england patriots and 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. [applause] >> senator warren, if you will introduce two of our panelists. >> 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, codirectors 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 masters 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 cofounder 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, 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 like integral found the sports legacy institute. he currently serves as an advisor on the nfl players association matthew white traumatic brain injury committee and the ivy league multisport concussion committee. crist has received numerous accolades, including a trendy 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. >> and it's 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. and doctor jacob vanlandingham is the director of neurobiological research at how household -- tallahassee memorial hospital and he is a professor at florida state university's college of medicine. so what we will do, we will start with you, mr. nowinski, and just go right down the list what you're 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. >> thank you for the 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. unfounded executrix of the sports legacy institute, nonprofit organization dedicated to solving the sports concussion crisis through education, policy research. i have a personal relationship with concussion. tremendous concerns i've increased my risk of developing a degenerative brain disease in the future. it's my hope this hearing raises awareness of the urgent need for funding for research on traumatic brain injuries as well as vitamins opportunities we have for the prevention of the long-term consequences. i never had a second thoughts tt about confessions or brain injuries until i was 24. playing high school football and then at harvard. i became a professor with the wwe and ag i get to travel the world playing a bad guy or a heel who would insult the fans intelligence and she to win. it was a performance to entertain our fans and it was a lot of fun. but in a match i was kicked in the head by my opponent, and my world immediately change. my head became throbbing, everything got foggy and most important i forgot the script. i could remember how we're supposed to finish the match. after the match ou i stop by our athletic trainer who asked if i was all right. i like and i said i'm fine. even though the headache was killing me. the symptoms that expand beyond daily headaches to include depression and sleep walking and it would not go away but i lied for five weeks thinking i was doing the right thing. i met dr. robert can who helping understand all the beings and all the bellringers i've been getting over the years were actually confessions. to think that 24 i was learning for the first time how fragile my brain was in a critical wrestling with. and now i am a at a high risk for developing degenerative brain disease. my ignorance cos caused the mic, five years of my health, and i don't know what it's going to cost in the future. but chronic traumatic encephalopathy is what i fear most of it was first named punchdrunk in 1920 and large was ignored. in the last they could realize it obvious sex, we've known it affects boxers but now we know it affects other athletes, military veterans can even members of the general public. since we can't diagnose individual people we don't know how many people have it but early evidence indicates it's not insignificant. our brain bank, 58 of the 62 brings a former nfl players study have been found positive for this disease. and young athletes as young as 17. dr. lakey is connected to motor neuron disease. having my friend kevin kerner in the room who is courageously taken on this issue. aldie for the rest of the science to my friend, dr. stern. we need answers quickly. we don't know how big this problem is. it may be massive with 1.7 going to be ice a year, at least 3.8 million confessions. where to recognize contact sports are evolves and we still don't know what the full light effects are exposing children to repetitive the brain, because today's seven year olds, not the ones we're going to be. football helmets were different so please didn't hit others in a. soccer was not as popular as we don't with effects of a lifetime of headers are. we don't know these answers. it is a public health crisis. while we work to individually fund more work and we applaud the state laws that a change that would play sports, it's not enough. one of the things i do is i train wwii wrestles on concussion, which is fun. we think we can train adults even though it's difficult if we don't know if we can train children. the reality is we don't know, we have kids playing contact sports who don't recognize when they have concussion, and that of a dock on the sideline and that means with all the changes we've made, cte will continue to be a problem and will be a problem for our military veterans. a new initiative was announced today that would hope will prevent this weekend up with the santa clara institute of sports law and ethics on a camping to educate parents and coaches on the risk of heading in soccer before high school. we're joined by women's national team plays, former national team players brandi chastain, cindy, who won the 99 world cup along with our medical doctor to say the rally is we don't need the header token. the current guideline is 10. it may start earlier but it shouldn't happen. so to conclude we must not underestimate the long-term effect of brain injuries. with one in four boys and one of 16 girls playing contact sports were putting a lot of children at risk of cte but we owe them a soldier military veterans greater investment in to find ways to effectively minimize the negative consequences of this inevitable brain trauma. thank you. >> thank you, mr. nowinski. mr. you check. >> well, first of all thank you so much for this opportunity. is truly a privilege to be here before you to speak about something that is 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 don't know what my future is going to look like. as a river kid from a small town in minnesota, i don't 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 wer why wentn to play two years with the cincinnati bengals. i am now a husband and a father of three beautiful girls. so thankfully i don't have been 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've just taken a national sports initiative for the american academy of neurology, 27,000 now make up the academy. they are the league in neurology in the world along with a national foundation, the american brain foundation's 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 federal fourth, 2007. it was an amazing night in miami, florida, assistant on to the dolphins stadium come onto the biggest age in the world. i don't even know how to put into words, over 109 people tuned in to watch the indianapolis colts face off against the chicago bears. i'll never forget the two weeks prior, our kicker telling the team, don't you dare blink at kickoff. adam has already won three super bowls so he is quite the experience. but there i am on the field standing in between future hall of fame cornerback peyton manning and future hall of fame coach tony dungy. i remember adams words, don't you dare blink at kickoff. so they're adding is walking off the steps, the whistle blows, his hand drops in the releases the players. 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 expense of my life. we won the game 29-17, and forever i will be able to wear this ring on my finger and remember that king. it was a dream come true. two years later that dream was shattered. when i woke up face down on a training camp field and 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 became a priority is because at 29, i started to have memory problems. and it took losing my mind to care about my mind. my memories begin to fade away. in fact, one story i've shared is going home to minneapolis and spending time with friends of ours, my wife and i, sitting around a table, and that, my friend brought up his wedding and i said, why wasn't i able to be there? i got the strangest look from him. the table got quite and his wife for over their photo album from the wedding, and page after page, there i was as a groomsman in his wedding. 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 can't help now to throw myself into a new target, neurology. to tackle an opponent, brain disease, particularly the traumatic brain injuries and concussions. i have been in passionate the efficacy to fight the lies i've seen ripped apart by brian disease, alzheimer's, parkinson's, epilepsy, chronic traumatic encephalopathy. we need a national revival of funding to go into these issues so that we can find the answers. the use senators can really become our new coaches. you can help decide the game strategy, put in the countless hours of work and research and trading policies and change this nation, connecting people to the most valuable asset, their mind. it's, it's not just education and awareness but is changing the nature of a person. it's 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 trading an emotional connection between the world and neurology, because of neurology, our neurologists are who cradled our brains. it's time for all of us to realize how special our brains really are. i have a number of policies i would love to share for you and question and answer time. thank you. >> thank you, mr. you do. dr. vanlandingham -- mr. utecht. >> thank you mr. nelson, 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 experts with brain injury. i was not playing football. i was actually assaulted. i was down in gainesville and there's a vagrant who assaulted me and i'd three images on 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 to experience what a lot of us have experienced are not that lucky. i went home to do a degree, ph.d in nurse i can focus on research. most of my clinical and basic research over the last 17 years has been folks on traumatic brain injury. recently i put the last five years more focus into concussions a mild traumatic brain injuries. to give you a little bit of background, after what caused a concussion is the brain surface of slings forward and is accelerated and it's going to hit against the interschool on the frontal part of the brain and that is going to be kicked back the other wha way is goingo go through this sort of acceleration deceleration rabbit inside the skull to let people think the brain is only damaged by hitting the inner part of the skull but actually the brain is sort of like jell-o and the stretches. accelerating frontal portion of the brain goes faster than the back portion of the brain and it stretches the bring in between. it's about stretching the cause is sort of a breakdown in metabolism in the brain. it makes it with the brain functions are slower. electricity doesn' does one in e brain quite as well as it used to. when without a concussion often will be able to get to the right answer. we are just delighted, our thought processes are delayed in getting to the correct answer. so i think it's important we also note that not only are we having concussions in athletics can we've mentioned the military early. we mention the elderly and the false epidemic we have in the elderly. also at the problem with false and children to you don't want to forget the pediatric population. by midnight tonight nearly 30 children in this country will die from it traumatic brain injury. and a lot of folks will continue, a lot of these kids will have problems for the remainder of their life. it's important we put the focus across the age, across the lifespan. 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 10 days to get better, it may take them seven to 10 months, they get behind in school. they don't graduate with their fellow schoolmates. a lot of issues with pediatric brains, they are different and need to be respected when coming up with treatment compared to the adult. same goes for the elderly. so in the think about sports, we always go to the nfl and professional sports. i believe that we have an even worse problem in high school athletics. because it's 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 a high school player playing football it was 240 pounds, still big, it's with a tremendous amount of force and disengaging and having had contact with an immature brain, and that makes it that much worse. so when you have, after you have a concussion, most everybody thinks you go rest, you just get better. about 20% of people don't get better. they end up with what's called postconcussion syndrome, which chris other two earlier, and have it ruined his career. it takes months or years to get over postconcussion syndrome. but we also see one of postconcussion syndrome is was he allowed to sleep difficulty. if i had a dime for every person i knew who had head injuries that have sleep problems, and thusly problems we never recognize that. whenever put efforts into trying to improve sleep patterns and that such a huge part of getting better, getting the appropriate sleep at night so the 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 things can be very subtle. each injury may be subtle and unique, the common factor is that when folks are injured and their athletes or in the military, they don't want to actually tell the truth. they want to serve intentionally mask it. the same thing goes with an elderly patient. an elderly patient doesn't want to lose their independence. they are not engaged and wanting to give up driving for 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'd 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're dealing with two major research and development issues. first, because concussions are compounding we need to develop new, acute pharmaceutical treatments. we treat everything else with the drugs. why don't we put a focus on develop 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's not a company issue. your mom -- you're not more likely to get a second concussion, and so on and so forth. the other thing we're up against, and i know doctor stern will speak more, too, is the issue of chronic traumatic encephalopathy. alzheimer's disease like pathology. these pathologies are also being seen down in the spinal cord, leading to lou gehrig's disease or anterior lateral sclerosis. we need to put a precedent on developing the 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 the drugs that can stop or halt progression of the pathologist associate with chronic traumatic encephalopathy. our company is coming developing an acute treatment for concussion. we will design it at the field deliverable. it will be a nasal inhalant to get more of the drug to the brain, a medic, and endless technician, an athletic trainer can give it immediately and we can stop the pathological consequences in its track. we also hope to be developing two new girl steroid drugs this summer which will be focused on alzheimer's disease and lou gehrig's disease. i'd like to thank you once again for the time he'd give me. thank you. >> thank you, dr. vanlandingham. we have to do with issues appear like the cuts in funding to nih. and having to restore those. the we are very sensitive to what you say. doctor stern. [inaudible] >> turn your mic on. >> good afternoon. thank you ranking member collins and tasting which most of the committee. it is a great honor to appear before you today. my name is dr. robert stern, a professor of neurology, nurse or jury and anatomy in her biology at boston university school of medicine. i'm also the director of the clinical core of the boston university alzheimer's disease center, one of 29 countries funded by national institute on aging or for the past 25 years i've been conducting clinical nurse science 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've 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 is a unique disease. easily distinguished through postmortem their pathological examination. originally called punchdrunk or dementia -- in the early 1900s when it was believed to only occur in boxers. cte has now been found in individuals from age 17-98. 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 progressive destruction of brain tissue. these changes in the brain can begin years or even decades after the last trauma, or after the end of athletic involvement, and could lead to memory loss, poor judgment, impulse control problems, aggression, rage, depression, suicidality, and mood problems, and yes, dementia. i've 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, and her team. from these interviews i have begun to learn about the clinical course and presentation of this disease, but more importantly i've learned about the tremendous team and suffering the family members experienced while their loved one's life was destroyed by cte. i've also been privileged to meet over 70 former nfl players have come to boston to participate in my nih funded detector study. i hear their stories. i speak with the 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 become an expected consequence of playing the game they love. the goal of the detector study is to develop objective biological tests, or biomarkers to diagnose cte during life. just as a separate note, right now today in this half-hour the first nfl players, former nfl player in our study is going to undergo a very exciting new standards designed to detect the abnormal definition of a protein found in this disease in the human being while they are alive. it's happening this afternoon. this will hopefully improve our ability to diagnose cte, and that indeed, the ability to diagnose cte during life isn't 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've been hearing today a lot about concussions. we been hearing a lot about concussions in sport and in the military. but the thing i'm most concerned about are what we refer to as subconcussive 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 concussions. those can happen many, many more times than anyone ever expects, 1000-1500 times in a typical football climate, perhaps 1000 times during heading in a season in soccer. that's what scares me your in order to tackle a 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 multidisciplinary collaborative research across research centers, bringing together the very best sites is, 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've been hearing mr. coors 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 towards 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 this limiters the similarities, it will expand our knowledge to other diseases like alzheimer's, parkinson's and lou gehrig's. in closing, many of her 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, develop methods of preventing and treating the symptoms of cte. i want to close by thanking the committee for interest in addressing this important issue, and for your commitment to improving the health and well being of older americans. thank you. >> finca, dr. stone. senator collins. >> thank you, mr. chairman. first i want to thank all four of our witnesses for truly exceptional testimony. mr. you check -- \mr.{-|}\mister you check, your statement was so moving and so riveting. you mentioned during the course of your comments that when you're strapped to the structure that that was your fifth documented concussion. what happened after the previous four times? were you treated each time? did you try to conceal that you had a concussion such as mr. nowinski mention? tell us what happened. >> sure. thank you for those questions. a number of answers to have ever concealed that i've had a concussion -- a concussion which is ahead. there's tremendous pressure in professional sports to want to continue to play, not only can you don't want to let down your teammates who become your family. you don't want to let down your coaches who you worked countless hours to put together a successful plan, and an injury can remove you from the plant and you don't want that to have an effect on the team. so yes, i was put in a position where, i wanted to play and that pressure get 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 the tackle as his foot lightly grazed 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 sidelines, and i have no memory of that. it was the first time i ever experienced amnesia and that was midway to the first quarter against the denver broncos in december 2007. i don't remember anything from that game and to we went in at half-time. and that really became, once the time a begin expensing short long-term memory issues which led to my final concussion that was an eight-month rehabilitation process. each team at the time was set up different with the 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 nerve psychologist who treated with concussions. answer think that's one of the things we really wanted to change is making sure the players are asked the same a neurologist who are those by the experts that can diagnose and manage concussions properly. >> mr. nowinski, the comments we 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 bigsby, meditation come to him who was a veteran, and he is being treated for post traumatic stress syndrome at the va in maine. and the doctors, and they're all just asked him if he ever had a concussion and it turns out that he 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 costume to have a form of epilepsy, which the neurologist been treated him for. so my question to you is, is it your experience that patients with neurodegenerative diseases often have a difficult time in getting a proper diagnosis? >> thank you, senator. that is a great question, and answer is there's no question that former athletes have a very hard time getting the right diagnosis because cte is so new that we're not, we have been paying for a medical school and has been widely ignored and continued education. interestingly when they go for brain bank records almost everybody who eventually misdiagnosed with cte was originally diagnosed with alzheimer's or an abnormal type of alzheimer's, or some other similar disease but almost, in the last couple of years none of them were getting cte as a diagnosis, meaning they were probably being mistreated. is dr. stern alluded to had just horrible this disease is for the individual and especially their families, it's 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. that's something i hope for myself. because i'm 35 now and the average onset of symptoms is usually to these people in their 40s, and so there's not much time left for me and it certainly ticking clock for a lot of people. >> dr. stern, i was struck when i do talk about a new imaging, and you mentioned that individuals with cte have the protein, and i know from my work on alzheimer's there's the protein is present in the brain of people with alzheimer's also. so are we talking about the same protein. is there a link? >> it's a wonderful question and this one of the things that is so exciting about working in this disease because there is a definite link, but yet they're completely distinct. the difference is that in alzheimer's disease that are two proteins that start taking a leading in an abnormal fashion and is an abnormal form of the protein to what is called tau protein and one is called amyloid. in cte we don't see the amyloid. and when we do see it's not in the same kind of plaques that we see in alzheimer's disease. and so cte is very specifically a tau protein disease. the type of formation and the places in the brain where it starts getting late is quite distinct from what we see in alzheimer's disease. and so to answer the question, we have to understand that we can't write a diagnose these neurodegenerative diseases accurately while people are living. including alzheimer's disease. we've been sending alzheimer's disease since 1905 when it was first discovered, and yet we still can't truly diagnose it during life. fortunately, we're getting very, very close. in large part to the help that this committee has given to support research. but we still can't do it. with cte we've only been studying it really in depth for the last five, six years. but what we able to do and what we're doing with my research right now is exploring 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. >> thank you. >> well, is there something that we need to be aware of with regard to helping you in the extreme edition on living patient's? >> money, money, money. that's what it comes down to. but it isn't 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 question the right way, costs tremendous amounts of money. and encoded to get to some answers quickly, we must have the adequate resources to do so. so yes, indeed, we need continued assistance in increasing the budget, 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. >> 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 country bidding 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 research that you bring to this table. and just to add to the chairman's question, money money money is often very important. but it's also how the money is spent. and also what can be done to prevent cte. one of the areas as education or the core eastern institute at the university of connecticut has released, as you know, a list of nine recommendations for blessings the incidents and reducing -- lessening the incident of long-term traumatic brain injuries and expense of the state and adopting those recommendations is very, very mixed. connecticut has implemented only 4. most of the states have implemented a few 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, unknown to me, concerns horseback riding, which is, in fact, the leading cause of sports related traumatic brain injury out of all the records in sports. think of it, horseback riding is the leading cause of sports related traumatic brain injury. why? because a lot of young writers -- riders are wearing helmets made of velvet with no real protection to think of a football player blaring a velvet helmet, nothing more. and so, in fact, i am planning to introduce a measure, which i'm aiming for a young woman, kristin o'donnell from connecticut who was thrown from a horse while writing, suffered a traumatic brain injury and died the next day. she wore one of these traditional velvet caps and it was sold alongside safety certified helmets, but her parents had no idea that they were buying a decorative helmet, rather than a real protective gear. so the bill that i will introduce, kristin o'donnell he questioned safety helmet act, would require a question how it's produced and in the united states to meet minimum safety standards. i don't want to go too much into detail because i've 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'm sure we will be talking about them in the near future. i'd like to ask mr. no wednesday -- mr. nowinski, you're now 35, your injury occurred when they were 24. how are you feeling of? >> thank you for asking, senator blumenthal. it's up and down. i mean, these days i stood away more headaches than i would like you. the last two days were very tough but right now i feel pretty good. but, you know, as part of dr. stern's legend study, i did my annual phone call testing my cognition and it was that i was proud of and stuff i didn't feel so good about. i'm happy where i am, but i'm always wary of where i'm going. >> the kick in the head that caused your injury was in a sense a routine part of the sport, cricket? >> it was an accident. we are not supposed to actually do that, just so you know. >> but accidents in that sport triple-decker. in fact, they are sort of part of the routine because, well, you say in your own words, but when you're in a contact sport of that kind, particularly where the routine, so to speak, is to actually do damage, at least fake damage to another person, it's easy to make a mistake, just like if you're throwing a fake punch. if you do it in the wrong way you're going to hit the person, with a real punch. and this must have happened to you repeatedly before that one as you say in your testimony. you suffered repeated blows to the head over the course of the sport and so forth. in your experience, are people in that sport, call it a sport for the moment, wwe wrestling or similar kinds of sports, aware of this repeated impact and effect of the routine blows that are struck? >> actually, yes. wwe has become actually a close partner in the last few years. we action honored them with her annual impact award last you because they have become a real leader on this issue. >> you purchased it in some of the educational sessions to write. 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. and made a $1.29 unrestricted gift to support argued at the boston university. it's been very rewarding to see that culture change so quickly -- $1.2 billion. they have protections in place that will hopefully minimize the risk of long-term damage. >> 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 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? >> yeah, you know, it's difficult for me to speak to all insurance programs because i know there's been a lot of changes, especially recently in many sports to provide for more medical care long-term. i think you make a good point that it's extraordinarily expensive to do with these consequenconsequen ces long-term. so i can pass that down the panel but it is a significant issue. >> thank you. >> i'll 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. we have to get reimbursement, we have to come up with other things like claim there's memory impairment and we get reimbursed based on that code but they're still very specific code and multiple hmos that will reimburse concussion in this fine world. >> is better in medicare as well? >> so 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 doesn't present exactly the same way as alzheimer's disease in other dimensions. 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 a much more limited. >> senator, before i return to you, i want to get an understanding of how could the concussions have an effect upon lou gehrig's disease, als, that our special guest is afflicted with? >> so again, just want to underscore that it's not necessarily concussions. it's the overall repetitive or brain trauma, including all those subconcussive hits that don't result in someone at all being knocked out or having changes in symptoms. it's a little hits over and over again that may start this escape the changes in the brain cells that lead to the deposition of this abnormal tau, leads to the destruction of the brain as people live longer. what we've 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. .. research at places like boston university that focus on traumatic train injury, revealed athletes and people with traumatic inseparate lopathy or cte, similar to patterns for brains with alzheimer's disease. patients have similar symptoms. we've been talking about this but i want to ask it a little bit differently. we don't know the root causes bus not everyone with a head trauma develops cte and not everyone develops alzheimer's disease as they age but we also currently lack effective diagnostic tools or treatment for either disease. the question i like to ask for dr. stern and dr. vanlandingham, how can you use what you learn about traumatic brain injuries to inform of the study of other age-related neurodegenerative diseases? dr. stern? >> senator warren, thank you for the question. that led me to get involved in the study of cron tick traumatic inseparate lopathy. as always himmers researcher i was never interested in brain injury and chris know wins ski's roommate was in the audience and we connected and led me to find out what was a burgeoning topic of. chronic traumatic inseparate lopathy. the reason i got so with cron thick traumatic encephalopathy we know the variables. necessary variable is repetitive brain trauma. that is not the sufficient variable. not everyone that hits their head is going to develop this disease. we know everyone who had the disease had a history of repetitive brain trauma. by that nature we're able to then look at the a group of people at high-risk, very high-risk for developing this disease and study them longitudinally and use new diagnostics tests to detect when the disease might start and follow them until death and have my colleague dr. mckeen and other neuropathologists examine them. that is unique thing. in alzheimer's disease we don't know who is very high-risk for getting it until later on we might do a pet scan that detects the amount of amyliod in the brain. we can use both sides of the picture to inform the other and get to answers in much faster answer. >> dr. vanlandingham, did you want to add anything to that? >> i reit a little bit no one brain is the same. most common questions i get from parents, when should i make my son or my daughter stop playing this sport? how many concussions? you know, i'm like, well everybody's different. you would like to say after three they're predisposed to cte. it is a very complicated answer but i agree with dr. stern it's a special population that can be measured, in the years to come and you will get closer to the right answer. i'd like to add one more comment to the lou gehrig's issues. i do a lot of preclinical research with animals and we can give concussions, even one single concussion to an animal and we find the protein in the cerebral spinal fluid. that fluid not only bathes the brain but also bathes the spinal cord. it could be a issue of transferal from the brain damage of the pathological proteins down into the spinal canal and some level of fusion but we don't know yet. but definitely bathe the spinal cord after a brain injury. >> our comments, both of us, dr. stern and dr. vanlandingham, remind me the wonderful thing about science that discoveries don't occur in isolation. what we learn by studying one disease can pay dividend in shedding light on other diseases. the director of the national institute of mental health, dr. tom insel told the health committee last year that we are on the cusp of revolution in brain research because of the incredible tools now available, that hadn't been there before. and yet, tikrit call moment, we're cutting back on nih funding. year after year adjusted for biomedical inflation, nih's budget has shrunk to the point we're now investing less in research within nih than we were in in 2001. let me ask the question this way, if we could double the budgets of your centers, how much could you do and how much faster could you do it? >> i will go first. >> show us the aspiration, sir. >> with a double budget we wouldn't just double the speed which we could answer important questions. it would be an exponential increase. >> yeah. >> one of the things that has been happening across the nation has been the loss of young investigators and senior investigators. young investigators because are no jobs for them because of nih cuts. there are no jobs for young postdoctoral fellows or new researchers trying to get a system professorship. senior investigators who have been working for decker decades are having to close their labs because for the first time ever they have no funding. because of that, we can't have continuity in research. we can't have numbers of people to be able to focus on a particular question at any given time. so that is one of thing points why we would have much faster answers, if we have more money we would have a meaningful staff to answer the questions. but we would also be able to do much more with technology and that's what's 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're putting one of our former nfl players in a pet scanner to be able to look at tau protein in their brain. it is first time we're doing it. it is very exciting. by being able to have support for that, to double the budget, continue the research, not to close it down, we would be able to be, be able to diagnose cte during life very, very accurately within the next five years. >> amazing. dr. vanlandingham? >> so i will start by saying i work for two different non-profit companies for a for-profit company and professor at academic institute and there are various thoughts that go through my mind to answer this question. i think if we had fund from the federal government let's say, that would sponsor private companies that would be easier for private companies to get investors, it would improve the value to the investor by having federal government support. now, is a little out there. big pharmaceutical companies don't do r&d anymore. smaller companies are now the ones that 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 never hardly ever try do commercialize them because they do not have the means which to do that. your question on, how much money doubling the budget. for 20 until dollars in a year i could be in a phase two clinical trial for concussion, first drug, if i had $20 million today, in a year i could have us in phase two clinical trial. >> i appreciate it. we talk a loot on this committee, for example, about alzheimer's and the alzheimer's association says as our nation continues to age, alzheimer's disease is projected to cause, 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 how much money we have to spend to care for people and so, i just want to take it again clear. we can not 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 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. >> 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 don't 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? >> the brain does not know what's 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 blasts 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's a different type of injury. that's 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 get, let's say in a football stadium is not necessarily going to be that same type of, you know, 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 sheering of those neurons that lead to this metabolic crisis within the nerve cells. it doesn't matter how the hit happens. that same type of change is going to occur, leading to the same type of acute symptoms. >> i want to ask mr. know wins ski and mr. utech, do you have any player you suicide. >> that is the last thing you would want to see anywhere. there is not enough information to say they are connected. that is one more thing funding into research would help us provide, more context with relationship with depression and traumatic brain injury. at some point it is not there yet. we look to some of the players who come to that point, it is really hard to make that connection yet today between traumatic brain injury and suicide. >> thank you for the question, chairman nelson. suicide is extraordinarily complicated but there are some things we do know. one, acute concussion, acute tramatic brain injury increases your risk of suicide or suicidal ideation one the next year from studies. we have a brains from brain banks with teenagers taking their life 36 hours from suffering post-concussion syndrome so there is something going on there. people committing suicide wcte hard to know if the you suicide was linked to depression issues that the disease brought on. it has alienated them from their families and they are not able to work and become isolated. you sometimes wonder and guilt and 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, how much this disease does affect families. >> if i could add 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 ami gdi la the home of emotional regulation and 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 and they have lag of control of impulse, that may lead to tragic recipe that may turn to suicide. >> are women more subject to this type of injury than men? >> 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 it is likely biomechanical, they have thinner, less muscular necks, their head, takes less of an impact to move their head rapidly and move their brain quickly. because of title ix and women have not been playing organized sports as long so we don't have a, and we don't have a handful of women in our brain bank and we don't have a positive case of cte so we're not going to sure to see there but it is concerning. >> if you're the team's coach or doctor, what is your best way to make an assessment as to whether or not your players should be able to continue? >> i would say first you do a memory and attention test there on the sidelines and now adays we know at love 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. >> and does that get into that impact, the immediate post-concussion assessment and cognitive testing? >> so the impact test is a, the most common cog nist tiff assessment for sideline, not really sideline testing but for athletic testing. it is used most commonly as a baseline test before a season. 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 till the next day. and so if you're 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're not pushed in any way, shape or form to send someone back to play before they're ready. >> 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 don't have to get back to what truly is their normal baseline but one that has been fabricated because of choices they made during the test taking. this is about changing the nature of this injury as well and really getting people to care about their brains so they don't make choices like that. >> and in this case you mean that that enables them to get back out on the field? >> well, correct. it takes, it takes, their baseline and lowers it so that their results don't have to come back to what really would be their normal baseline. >> i see. >> they wouldn't be taking that impact until the day after. >> correct. >> you're doing a sort after quick and dirty on the sidelines whether they can go back in immediately or not. then you're holding them out and doing the check toward the baseline the day after. every seven days until they return to normal. >> 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 we do know about the donations buy the out come of the research. >> i can speak to the donation of 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. so the goal of the nfl giving that money so that it didn't have any conflict of interest. so there wasn't 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. >> okay, now, final question. a recent medical journal said emergency room visits for sports-related tbis have increased by 92% over then year period. you're a parent. you have a child. they want to play sports. if it's a contact sport, do you let them play? let's go right down. right down. mr. nowinski. >> after a doing this -- >> i will keep you short because we have go vote. >> i would say no contact sports with repetitive brain trauma before high school. after that, i do not have kids yet, i would say not let them get hit hundreds of times before high school. >> i would have to agree with mr. nowinski. a high school in texas has gone to flag football up to high school. players in the nfl, didn't play football in college, they were basketball players but became pro bowl players in the nfl. can you remove cac sports in high school and still teach fundamentals, even correctly how to tackle but removing the contact? i really believe that you can. >> doctor? >> i agree. i discuss still have my concerns about as large and as fast as high school players gotten today, there will still be a major issue. but at least we removed anybody under the age of 15 or 16 from being engaged in it. >> dr. stern? >> i think we've 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. that is before we have adequate science. however, we also have to think rationally and make rational decisions. i think people are now understanding hitting your head over and over again is not necessarily a good thing for you. so i would agree with everyone else, at the very least, contact sports with repetitive hits to the head should be limited to as late as possible. >> we especially want to thank our special guests and again we want to thank all of you. >> mr. chairman. >> senator. >> i apologize for interrupting i wonder whether the record can could be kept open, this is such a phenomenally good panel i have i have questions i would like to submit. >> the record will be kept open for five days. the meeting is adjourned. >> thank you. [inaudible conversations]. >> this is part of our week-long look at health care related congressional hearings. if you missed any of this hearing we'll air it again later tonight at 6:00 p.m. eastern. tomorrow we continue with a hearing focusing on cronic illnesses before wrapping things up on friday with a discussion about patient safety. here is a look what is coming up today on c-span2. next part of a congressional hearing on the future of the export-import bank. then today's edition of "washington journal" in its entirety. today, another look at the hearing on brain injuries and the elderly. join us tonight for more from booktv our focus this evening, american astronauts and space travel. you will hear from authors, including lynn scheerer to wrote a book about astronaut sally ride. on c-span3 on american history tv. tonight's theme, the cold war, we'll look into the fall of the berlin wall and other things. on c-span we kick things off 8:00 looking at social work in america, steve perry the founder and principal of a magnet prep school that only accepts first generation low income minority students. he talks about the improving lives in minority and impoverished communities. this weekend on the c-span networks, friday night on c-span, native-american history. then on saturday, live all-day coverage from the national book festival science pavilion. saturday evening from bbc scotland, a debate on scotland's upcoming decision whether to end the political union with england. sunday q&a with judge robert katzmann, chief judge of the second court of appeals. he shares his process determining last passed by congress. "in depth" with former congressman ron paul. on saturday, all day live coverage of the national book festival from the history and