Back page of the Daily Mirror claims a report into Dementia will shock all football fans, I did a report on this for a university project back in December 2020. This is everything I thought I should include, I might even add to this over time. Ironically they used the same Jeff Astle picture as I did for my report.
Are Head Injuries in Football Taken Seriously Enough?
Introduction
For this report, I am going to investigate the link between head injuries or chronic traumatic encephalopathy (CTE) and dementia. It’s becoming more apparent that former players didn’t have the same protection or scientific information regarding what the potential problems were and what the long-term effects could be as players do today
For research purposes I am going to focus on football,as it has been reported to not have correct or consistent protocols compared to other sports. I will refer back to other sports regarding how they process on pitch injuries and concussions, which cause repeated minor trauma, and the route back to playing once the player has been diagnosed with concussion.
I will briefly focus on the restrictions that have been put in place by the FA at primary school to under 18 level. These restrictions are a big step in making big changes to a system that hasn’t changed for years.
What is dementia?
The word ‘dementia’ describes a set of symptoms that may include memory loss and difficulties with thinking, problem solving or language.
These changes are often small to start with, but for someone with dementia they have become severe enough to affect daily life.
A person with dementia may also experience changes in their mood or behaviour.
Dementia is caused when the brain is damaged by diseases such as Alzheimer’s disease or a series of strokes. Alzheimer’s is the most common cause of dementia,but not the only one. (What is dementia, 2020)
The five different causes of dementia are:
• Alzheimer’s disease – This is the most common cause of dementia. In Alzheimer’s disease, an abnormal protein surrounds brain cells and another protein damages their internal structure. In time, chemical connections between brain cells are lost and cells begin to die. Problems with day-to-day memory are often the first thing to be noticed, but other symptoms may include difficulties finding the right words, solving problems, making decisions, or perceiving things in three dimensions.
• Vascular dementia– If the oxygen supply to the brain is reduced because of narrowing or blockage of blood vessels, some brain cells become damaged or die. This is what happens in vascular dementia. The symptoms can occur suddenly,following one large stroke. Many people have difficulties with problem-solving or planning, thinking quickly and concentrating. They may also have short periods when they get very confused.
• Mixed dementia – This is when someone has more than one type of dementia, and a mixture of the symptoms of those types. It is common for someone to have both Alzheimer’s disease and vascular dementia together.
• Dementia with Lewy bodies – This type of dementia involves tiny abnormal structures (Lewy bodies) forming inside brain cells. They disrupt the chemistry of the brain and lead to the death of brain cells. Early symptoms can include alertness that varies over the course of the day, hallucinations, and difficulties judging distances. A person’s day-to-day memory is usually affected less than in the early stages of Alzheimer’s disease. Dementia with Lewy bodies is closely related to Parkinson’s disease and often has some of the same symptoms,including difficulty with movement.
• Frontotemporal dementia (including Pick’s disease) – In frontotemporal dementia,the front and side parts of the brain are damaged.Clumps of abnormal proteins form inside brain cells, causing them to die. At first, changes in personality and behaviour may be the most obvious signs. Depending on which areas of the brain are damaged, the person may have difficulties with fluent speech or forget the meaning of words.
The concussion protocols
You can look back to the iconic image of Terry Butcher being covered in blood from a head injury when England took on Sweden in an Italia ‘90 World Cup qualifier to know that head injuries weren’t taken as seriously as they are now.
Bobby Robson, the England manager, told Butcher to go back out for the second half and Graeme Souness (Rangers Manager) told him he’d be fine and to carry on when he got back from international duty to train with his domestic team (Butcher, 2018). I think if you asked Souness, it would have been a different story now and the FA have put a set of protocols to help with concussions and head injuries.
The FA have a specific list of questions to be asked of a player who has sustained a head injury, and more likely than not, these were asked to Arsenal defender David Luiz after a clash of heads with Raul Jimenez of Wolverhampton Wanderers. The Wolves striker has since had surgery on his fractured skull, Luiz was deemed fine and able to drive home on his own, which wouldn’t be allowed in both rugby codes, ice hockey or NFL, we will visit those later in the report.
These questions are:
• What venue are we at today? Or Where are we now?
• Which half is it now? Or Approximately what time of day is it?
• Who scored last in this game? Or How did you get here today?
• What team did you last play? Or Where were you on this day last week?
• Did your team win the last game? Or What were you doing this time last week?
The guidelines state:
an incorrect answer to these questions may suggest a
concussion, but a concussed player might answer
these questions correctly
(The FA’s Concussion Guidelines, 2019)
For players who are kept off the pitch and unable to return, there are very strict guidelines to how they return to playing for the club. This is called the Graduated Return To Play, GRTP, Protocol and has six distinct stages that must be followed as shown.
Even though these stages are put into place and people do work within this system, it seems it’s a very confusing area when the questions that are asked don’t actually give a definitive answer to whether or not a player is concussed.
Dr Willie Stewart, a Neuropathologist, is the lead researcher for the University of Glasgow’s ground-breaking study into concussions and the link to dementia.He has asked for the introduction of concussion substitutes so players can be properly assessed over a brief period of time.
This is a moment to say our management of head
injuries across all sports must improve from today.
All sports should be doing the same thing. We should
not have a position in rugby where a player is going
off for 10 minutes to be assessed with really
sophisticated sideline assessments and, in football,
they are still managed on the park. You need to have
a 10 minute assessment at least and, if that means
a substitution goes on, then that’s fine. This is
protecting a players brain. Sports has to stop talking
about consensus in the management of concussion
and deliver consensus.
(Telegraph, 2019)
It’s clear to see from what Dr Stewart has asked for that the governing bodies aren’t doing enough to protect players from what could happen as they get older, in some instances the player wouldn’t have to be that much older than when they retired from the game. Two stories have been released concerning rugby union players with early onset dementia symptoms, the same as Astle’s original diagnosis. Both Alix Popham, 41 years old and Steve Thompson, 42 years old are examples of this not being something for the elderly only.
Dr Stewarts research has taken results from ex-professional players in Scotland that were born before 1st January 1977 and they were all male. (Mackay et al, 2019)
Former professional soccer players were identified from
databases of all Scottish professional soccer players
that were compiled from the archives of the Scottish
Soccer Museum and the individual league clubs.
Available data included the full name and date of birth
of the players and career information, including dates
of first signing and retirement, number of match
appearances, and player position
(nejm.org, 2019)
To illustrate the issue with dementia being linked to head injuries in football, and even though it would seem that the percentage is relatively low, the tables below will show the differences in brain diseases,positions played and other primary causes of death.
The hazard ratio, a measure of how often a particular event happens in one group compared to how often it happens in another group, over time, might be low in numbers but it’s massively different to the other primary causes of death. A hazard ratio of one means that there is no difference in survival between the two groups. A hazard ratio of greater than one or less than one means that survival was better in one of the groups. (“Dictionary of Terms”, 2019)
This table clearly shows that ex-professional footballers were more at risk of dying at the hands of a neurodegenerative disease compared to deaths in the general population of males in the specific time set out during this study.
This table shows the difference between outfield players and goalkeepers. Obviously, outfield players would be more inclined to head a football on a regular basis as opposed to a goalkeeper, there are also a lot more outfieldplayers used in this study.
Former players with dementia
Dementia in former football players has been mentioned for years, Jeff Astle was one of the first high profile players within the British game that died from repeated minor trauma that had only been diagnosed as the brain disease five years earlier.
Astle was originally diagnosed with early-onset
Alzheimer’s, but a re-examination of his brain
revealed he died from CTE that a doctor said
was brought on by repeated heading the ball
(The Straits Times, 2017)
Danny Blanchflower, Tottenham Hotspurs most successful captain,died with similar symptoms to Astle in 1993, Alzheimer’s.
Other players include:
• Nobby Styles(1942 – 2020)
• Sir Bobby Charlton
• Ron Saunders (1932 – 2019)
• Rod Taylor (1943 – 2018)
• Peter Bonetti (1941 – 2020)
• Jack Charlton(1935 – 2020)
• Martin Peters (1943 – 2019)
• Billy McNeil (1940 – 2019)
• Jimmy Conway (1946 – 2020)
• Alan Jarvis (1943 – 2019)
New Technology
Football over time has embraced new technology in many different ways, these seem to have helped players as they don’t have heavy football boots, massive shin guards or heavy leather footballs that became even heavier in wet conditions. Some former players mention splitting headaches after training that could be relieved with ice packs on their foreheads (Winter, 2020).
'We had Alan Woodward, right winger, great crosser of the ball, and Len Allchurch, Welsh international who played on the left. They had 20 balls each to deliver, the old leather ones. When they were wet they were like bloody medicine balls'
Alan Birchenall (Winter, 2020)
Birchenall went on to describe the pain that he would endure after training sessions and this was all before he was 20 years old.
As recently as February,2020, the FA has updated it’s guidance for youth training sessions regarding heading a ball. These include:
The leather balls used back in the 60s and early 70s are a far cry from what the players of today have to deal with, many of the players that Birchenall played with would have all been running the risk of dementia in one way or another from the CTE.
Footballs are now made out of a synthetic leather as its thickness varies far less than real leather, as well as a latex or butyl bladder and a number of additional layers covered with a waterproof coating (Football Technology, 2018)
These new footballs enable players to bend, curl, hit with more power and head from almost one penalty box to another in some cases. This would never have happened back in Birchenall’s day, but they were masters of that part of the game, now trying to help the current generation with warnings about what they did along with the help of top scientists from around the world
What can football learn from other sports?
Other contact sports all have their own protocols to follow and maybe football could take some advice from all of them to come up with more of a workable plan going forward.
These directives have all come into place due to the severity of injuries throughout the world and to help protect players.
Elite Ice Hockey Association guidelines:
Any athlete with suspected concussion should be immediately removed from play. They should not return to the ice, be left alone or left to drive home.
HEADCHECK is a campaign that launched in 2015 and they have cards that must be followed at the rink side. They ask medical staff to ‘Follow the Five S’s’, as shown in the poster below.
Rugby Union Guidelines:
The University of Bath pioneered a study in in rugby which involved the RFU and even had England training in Bath so they could test the results. This study helped to implement the new scrum guidance of ‘crouch, bind, set’ which reduced front row forwards impact when binding in a scrum.It demonstrated a 25% reduction in the forces of engagement. It was rolled out by World Rugby in 2013 at all levels of the game from youth rugby to international and its long- term impact is hugely significant (MadeAtUni, 2018)
Bath has become a hub for this research for rugby and they have returned to complete a study for youth and community rugby regarding soft tissue injury reduction
All Athletes with any symptoms following a head injury:
• Must be removed from playing or training
• Must not return to playing or training until symptom free or until all concussion-related symptoms have cleared or have returned to pre- concussion level
Rugby League Guidelines, HEADCASE:
Just like union, league is very cautious and aware of the potential injuries that could come from concussions and have ‘Headcase’ in place which all league teams, whether a professional team playing in super league or a youth team. They stress that youth rugby players are more susceptible to concussions and take longer to recover (Headcase, 2018)
League have every angle to this covered regarding information, all teams have an overview which gives a detailed account of what to look for along with having pitch side cards to assist medical staff. Football has adopted the league slogan“IF IN DOUBT, SIT THEM OUT”.
The 4 page guideline ask for officials to remember the 4 R’s , Recognise, Remove, Recover, Return
National Football League guidelines:
Probably the most intensive and thorough guidelines after the NFL ploughed
$40 million in funding the Play Smart. Play Safe. Initiative for medical research over five years, primarily dedicated to neuroscience (NFL Health & Safety I NFL Football Operations, 2020).
The funding didn’t stop there with $14 million to the Foundation for the National Institutes of Health to advance medical research on brain injuries,especially among athletes and veterans (NFL Health & Safety I NFL Football Operations, 2020).
They made improvements to the already rigorous protocol for the 2018 season which included going into a sideline medical tent. These protocols were developed back in 2011, well before anything was put in place for the European version of Football.
The Jeff Astle Foundation
In May 2014, Jeff was confirmed as the first British professional player confirmed to have died from chronic traumatic encephalopathy (CTE), 12 years after death (The Jeff Astle Foundation, n.d.). His family wanted to make sure that more was being done to as even though the importance of these issues were being talked about, the awareness was, and could be considered to still be low. It’s only in the last 18 months, since Dr Stewart announced the findings from his research,that more is actively looking to be done by the FA and other governing bodies of association football.
The family of Jeff Astle are launching The
Jeff Astle Foundation on April 11th 2015.
The Foundation is to be established in
memory of Jeff Astle as a fitting and lasting
legacy to both raise awareness of brain
injury in all forms of sport and to offer much
needed support to those affected.
(The Jeff Astle Foundation, n.d.)
Moving football forward
In conclusion it’s clear to see that football has a lot of ground to make up so that is looking out for the health of the players, after they finish playing the game they love,first and foremost. The steps are being made slowly with the introduction of new guidelines within youth football and with Dr Stewart still making progress along with other leaders in the field of neurological disease, you’d have to hope that the governing bodies of world football will start to take notice.
The FA have the potential to shape the game in a way that will benefit these players who will put their bodies on the line for a moment of glory with the fans.They should look in to the possibility of having the 10 minute concussion substitutes, like Dr Stewart suggests. The player who’s just taken a huge knock to then have the time to come around instead of thinking he needs to get back on the pitch as they are a man down. He clears all the protocols put in place and he can go back without it affecting the number of substitutes used.
The FA should also look to the other sports, especially NFL. They have taken time to research and make a plan that is by far the most expansive,they could even talk to the team at the University of Bath and spend time working on developing a structured plan for the future.Scrums in rugby might not look as good as they used to but the safety of the players comes first.
It’s hard to see why something hasn’t been done sooner, is it through worrying whether they’d have to ban a fundamental part of the game, heading a football. That would only ever be a last resort and they must be prepared to take any measures necessary to stop that from even being a suggestion.