Special feature: Should head injuries in sport be taken more seriously?

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Cardiff City’s Kenny Miller suffering from a head injury

With a number of high-profile head injury incidents hitting the sports headlines, Alex Bratu investigates whether current protocol and rules are protecting players from potential brain injury that can last for the rest of that person’s lifetime.

On a brisk and blustery Wednesday night on the south coast of England, former Premier League champions Chelsea suffered an embarrassing 4-0 defeat to bottom half team Bournemouth, in a game that heaped pressure on the West London side.

Following the game, pressure was also heaped on the Football Association over an incident in the third minute of the match, which saw Chelsea defender David Luiz seemingly knocked unconscious for a brief while, after suffering a strong blow to the side of the head with the ball.

Following treatment, the Brazilian was allowed to continue playing and looked visibly affected for the remaining 87+ minutes of the game as his side capitulated through defensive lapses in the second half.

It led to questions as to whether Luiz had played the remainder of the game with some degree of concussion, and his involvement in the remainder of the game following his collapse was widely discussed on social media.

One such discussion was raised by American NFL star JJ Watt, who tweeted that concussion protocols are “a bit different across the pond”, suggesting that had Luiz been playing in the United States he would not have continued the game.

Would removing Luiz have been the right call? Was it dangerous for him to continue playing despite being visibly affected? Whose decision was it that he continued to play?

These are questions that have been raised again and again in football, with previous incidents involving Brazilian midfielder Oscar and French goalkeeper Hugo Lloris, who were both knocked unconscious before continuing to play in their respective games.

Following the incident with Luiz in January, a Champions League game between Tottenham and Ajax saw Belgian defender Jan Vertonghen incorrectly cleared to continue playing, following a collision of heads with a teammate.

The player wished to continue and was given the all-clear by the referee who paused the game to check him, but he grew weaker in the minutes following, calling for his own substitution and almost fainting upon leaving the pitch.

Incidents such as these have sparked widespread criticism from brain injury experts and charities such as Headway, who campaign for better understanding and reduced instances of brain injury and have said that it is in the process of writing to UEFA:

“We strongly believe the football authorities have a duty of care that should not only be enacted – but also be seen to be enacted.”

Head injuries in sport: what are the current protocols?

Following the Vertonghen incident, Tottenham manager Mauricio Pochettino told reporters that the medical staff followed Football Association protocols on suspected concussion, which state:

  • Play must stop as soon as a player is suspected of receiving a head injury.
  • Players must undergo a pitch side assessment which looks for signs of a concussion or brain injury (including symptoms such as loss of consciousness, confusion and nausea).
  • Players who are thought to have received a head injury must be removed from play, and not allowed to return to play or training for up to two weeks, following assessment by a medical professional.

But while these protocols were followed, their effectiveness was called into question given Vertonghen’s eventual exit.

Whilst guidelines are in place to limit the effects of head injuries in game, symptoms of brain injury do not always immediately present themselves, with procedures often complicated by players often wanting (and believing they are able) to continue the game.

Moreover, studies have shown that players who are returned to the pitch after head injury are three times more likely to suffer a second head injury.

Both rugby and American football have stricter guidelines than association football concerning head injuries during the game. In rugby, section 9.4 of the Rugby Football Union Regulations state that:

  • In specified adult competitions, participants who sustain a head injury or impact but show no signs or symptoms of concussion may be temporarily replaced for medical assessment and may only return to field of play if assessed and permitted in accordance with the protocols that apply to those competitions.

And NFL concussion rulings in the United States, which are enforced to protect players such as the previously mentioned JJ Watt, include:

  • When a potential concussion is identified the player shall be removed immediately from the field.
  • The NFL team physician and the unaffiliated neurotrauma consultant will review a video of the play and perform a focused neurological examination.
  • If there is suspicion of a concussion, the player will be escorted to the locker room for a full assessment.

Why are head injury rules stricter for certain sports?

The frequency of head injuries varies widely between sports, with association football (referred to as soccer in the US) averaging a rate of around 1.9 concussions per 10,000 “athletic exposures” (AEs), while the figures for rugby and American football are 3.2 and 6.4 respectively, suggesting that stricter protocols have emerged in sports where concussion is more common.

Concussion rates in US middle school athletes, 2015-16 (Kerr et al., 2017)

One Rugby Football Union (RFU) document also suggests that the level of incidence of head injury in professional rugby matches has increased drastically since the 2012/13 season due to initiatives and media coverage leading to an increased level of awareness in identifying potential head injuries.

Head injury incidence per 1000 player hours (Kerr et al.,2017)

Is concussion the only brain injury risk?

The Jeff Astle gate at West Bromwich Albion’s stadium The Hawthorns

In 2002 former footballer Jeff Astle passed away aged 59 from early onset dementia.

Coroner reports found that his eventually fatal dementia was caused by repeated minor traumas in heading a heavy leather football during his playing career.

His family have since launched the Jeff Astle Foundation to raise awareness on brain injury in sport.

Astle was not the first former footballer to die of a degenerative brain disease due to heading the ball: in 1993 Danny Blanchflower died of Alzheimer’s disease aged 67, raising concerns about the potential impact of the sport.

James Coxon of Headway says that they welcomed news that the Football Association and Professional Football Association (PFA) will now work together to conduct research to address both what has gone before and what is happening in the sport today:

“The families of those affected deserve answers that have for too long been denied them. We know a great deal more about the brain today than we did in the 1960s and 70s. What is still unclear is the extent to which heading old-style, heavy leather footballs could have contributed to players developing neurological conditions.

“Further research is also urgently needed to assess whether there is any risk to heading modern, lightweight footballs.”

As well as the PFA/FA research, the University of Birmingham is also undertaking research, working with Premier League players during the 2018-19 season to find ways to make brain injury diagnosis easier. Techniques identified by the research include pitch-side assessment and video review, and post-match clinical reviews. The university would not offer any comment on the progress of the research.

A lack of guidance on heading by children

Headway have also sought to raise awareness of the issue of potential damage to the brains of children in heading a football.

No protocol currently exists in the UK limiting the use of the head to make contact with the ball. However, in the US children under the age of 11 are not allowed to head the ball, and there is a limit on the frequency with which children aged 11-13 can head the ball.

I spoke to Harborough Town under 11s coach Francis Lawrence about the protocol around children heading the ball, who acknowledged the lack of guidance on the issue:

“There are no issues, either from an FA directive or from instructions within the club I’m at, regarding how kids head a football.

“The FA directives are not aware of anything to guide what we should or shouldn’t be doing.”

In 2017 the FA claimed there was “no real evidence” to stop children heading footballs, but pressure has grown since then, following research published last year and most recently from former Spurs player Ryan Mason. The FA told the BBC:

“We have commissioned comprehensive and rigorous research studies in this area, in collaboration with the Drake Foundation and the PFA, which are currently ongoing.”

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