Concussion
Football’s hidden epidemic
The sight in Andy Wilkinson’s right eye flickered and faded like a broken car headlight. A volley had smashed the Stoke City defender flush on the temple from close range and blurred his senses. “It was scary, but I thought I would be able to just run it off,” he tells Fourfourtwo. The right-back had a point to prove. He was out of favour but had been handed a recall for the Potters’ FA Cup Fifth Round tie against Blackburn Rovers and was determined to grasp his opportunity with both hands. “I didn’t tell anyone I felt unwell – I tried to hide it, but I was sick as I left the pitch,” he recalls.
Wilkinson was substituted at half-time. Medical staff realised he was suffering from classic symptoms of concussion: a traumatic brain injury, which occurs when a jolt to either the head or body causes the brain to move rapidly back and forth inside the skull.
He was convinced that it was nothing a tough defender couldn’t shrug off. After all, what harm could a lightweight modern football do? “I thought I’d be back in training on Monday morning, but as the days passed by I realised how serious my injury was,” he adds.
The 32-year-old began to suffer with vertigo – spells of prolonged dizziness which routinely saw rooms appear to spin in front of his eyes – balance problems and bouts of nausea. The damage to his brain, coupled with his struggle to come to terms with the setback, also saw him develop some anger issues and feelings of depression.
Wilkinson flew to America three times to undergo treatment from concussion experts, but he soon found there was no magic cure for his ills. “They told me it was highly unlikely that I’d play again, as the risk of another brain injury was too great.”
In February 2016, 12 months after his injury, Wilkinson was forced to retire. It was a blow even harder than the one that nearly rendered him unconscious. When he falls asleep at night, he often still dreams he plays football for a living, but reality hits home when he wakes up.
“The specialists don’t know if I’ll ever fully recover,” he says. “My depth perception – where I think I am in relation to objects – is not right. My peripheral vision is distorted and I do vision therapy every day. Special lenses alleviate the symptoms.”
Wilkinson’s story wouldn’t be out of place in a bygone era when footballers complained of headaches after heading soaking wet leather footballs for 90 minutes. But scientists now believe modern balls – which travel much faster through the air – could leave players equally at risk of suffering long-term brain injuries.
A machine fires off 20 footballs, one after another, towards a player stood inside a penalty area. The contraption simulates the pace and power of a typical corner-kick – but this isn’t a normal training drill. Twenty-three players’ brains are being tested before and after the practice session. They undergo the exact same tests for the next two days and then do it all again two weeks later.
Researchers at the University of Stirling carried out the study last October to reveal the impact of heading footballs on the brain. The results showed some immediate changes in brain function after just a single session. The players performed between 41 and 67 per cent worse in memory exams and a build-up of chemicals was found on their grey matter, which can make muscles more difficult to control.
The effects of the session lasted just 24 hours but lead researcher, Dr Magdalena Ietswaart, feels the findings were a cause for concern. “Although the changes were temporary, we believe that they were significant to brain health, particularly if they happen over and over again, as they do with heading a ball,” she said.
New research has revealed heading could endanger the long-term health of players. FFT finds out if the game has got an underlying concussion issue and how it could affect both current and former stars Words Alec Fenn
A further study published in February by the Albert Einstein College of Medicine in New York, quizzed 222 adult amateur footballers who played for at least six months of the year. They filled in questionnaires to see how often they headed the ball and were involved in collisions on the pitch. The results were again startling.
“We learned that heading the ball is indeed related to concussion symptoms,” said lead researcher Dr Michael Lipton. “This is contrary to previous studies, which have suggested that collisions are most responsible for concussions. The findings raise concerns about the long-term effects of heading the ball – more research is needed.”
The tragic case of Jeff Astle is a stark warning from the past. The former West Bromwich Albion striker – who netted 174 goals in 361 games for the Baggies and was the first player to score in an FA Cup and League Cup final at Wembley – did not recognise his family and died unaware he’d been a footballer, despite being surrounded by photos of iconic moments, medals and England caps at his home.
“Everything that football gave him, it took away,” Astle’s daughter, Dawn, tells FFT. He died in January 2002, aged 59, after a four-year battle with what was believed to be Alzheimer’s disease. Yet Dawn was convinced that there was a link between her father’s condition and the number of heavy blows that he had taken to the skull from constantly heading a ball during his career.
A coroner agreed with her. Andrew Haigh, who delivered the verdict, ruled Astle had died of an ‘industrial disease’ caused by repeated contact with the heavy leather ball used in the 1960s. He said that it had caused a level of trauma very similar to that suffered by a boxer at the end of a career spent absorbing the punches of heavy-handed foes in the ring.
The diagnosis wasn’t entirely correct, though. In 2014, Dr Willie Stewart was granted permission by the Astle family to carry out a re-examination of his brain. He found that he had in fact died of a condition known as Chronic Traumatic Encephalopathy (CTE) – a degenerative brain disease that can only be fully diagnosed in post-mortem and one normally associated with American football players and boxers with multiple concussions.
But is it possible that heading a lightweight modern football could have the same deadly impact over a number of years as the leather version Astle once compared to ‘a bag of bricks?’ It’s a question Eric Nauman, a professor of mechanical engineering at the University of Purdue in America and Larry Leverenz, clinical professor of health and kinesiology at the same school, have attempted to find out.
The pair have spent the last eight years studying concussion in women’s soccer and American football. In 2015, they tracked two female high school teams over the course of one season. Players wore a sensor called an xpatch behind their right ears during every training session and game, to monitor the G-force (g) of every blow to the head in excess of 20g and how the brain moved in the skull after each hit. They also recorded which types of impact caused the most force and took MRI scans before, during and after the season, to monitor all of the alterations in the brain.
They were taken aback by the results, with the force from heading goal-kicks and long balls far higher than expected. “Many of them were between 50g and 100g, which is the same as a punch thrown by a boxer or a collision in American football,” Nauman tells FFT. “They also suffered these blows at an average of 4.29 times per game. We don’t have the data yet, but it would be fair to estimate heading a goal-kick from a Premier League keeper could be 100g.”
At the end of the season, players performed two memory tests. The first required them to recall an image they had just seen, while the second asked them to remember the previous two images. “The brains of the players who had taken the greatest number of hits had to work harder at both tests than those who’d suffered the fewest,” says Leverenz. “The differences terrified us.”
Interestingly, although scans showed changes in the function of half the players’ brains, none of them displayed any symptoms of concussion. “If you bruise a different part of your body like your leg, you feel sore and so you rest up,” says Nauman. “However, the brain doesn’t have the same pain receptors to tell you that it’s hurt and to ease off, so you keep playing, heading the ball and causing damage.”
Nauman says smaller, repeated blows over a prolonged period of time can often be more serious than a single heavy collision. “If you look at an MRI scan of a brain that has taken lots of sub-concussive hits, it can look a lot worse than a scan of a player who has taken one big hit. If a player heads the ball regularly for 15 minutes, he’s absorbing a lot of force, so it won’t take a huge hit to knock him out.
“If you look over a longer period of time – let’s say you head the ball every day for six months – what happens is your brain remains inflamed for the entire time. If you have inflammation in the brain, it’s very different to other muscles in the body. Blood doesn’t clot like it does in skeletal muscle, so it takes longer to recover. If you don’t rest, there’s a risk of long-term damage.”
Nauman and Leverenz are keen to perform the same tests on Premier League players – but their ambitions have been met by a stumbling block. “We have not tested these guys yet because the Premier League and FIFA aren’t funding it,” explains Nauman. “We could do this study for the fraction of the cost of one player and get all of the answers from one study – then we would be able to protect players’ long-term brain health.”
A CORONER RULED ASTLE HAD DIED OF REPEATED CONTACT WITH HEAVY LEATHER BALLS USED In THE 1960S
Dawn Astle has been calling for the FA to invest money in further research since her father’s death in 2002. She wants the governing body to fund a study to determine whether there is a link between concussion caused by heading footballs and long-term brain injury. “We need to know if there is a higher rate of dementia in ex-players than the average population,” she says.
She launched the Jeff Astle Foundation in 2015 to raise awareness of brain injuries in sport and has since been contacted by ‘hundreds and hundreds’ of former players who are suffering with symptoms of dementia. “Four of England’s 1966 World Cup team have dementia,” she says. “Five of Aston Villa’s 1957 FA Cup-winning side have also died of the disease. The ratio’s too high.”
In 2002 the FA promised to launch a joint study alongside the PFA, which failed to materialise. “It’s 15 years since my father died, but we are still no further down the line,” Astle laments. “The FA have a duty of care across all levels of the sport. They don’t want to hear football could be a killer because they want to promote the sport, but people are dying. Players must know the risks.”
The lack of action from the FA bears similarities to the NFL’S initial stance in relation to American football’s own concussion epidemic. Back in 2002, Nigerian pathologist Bennet Omalu learned that the disease CTE – the same one found to have ravaged Astle’s brain – was devastating former players. His autopsy on former Pittsburgh Steelers centre, Mike Webster, discovered that repeated blows to his head during his career had caused him to suffer from the condition.
The NFL disputed the findings before mounting scientific evidence, court hearings and a lawsuit by former players forced the league to acknowledge the crisis and agree on a settlement, which could cost them $1 billion over the next 65 years. Could the FA’S lack of action be in fear of the financial repercussions?
“None of the families I’ve spoken to have ever mentioned money,” says Astle, “but football is frightened of what it is going to find out.”
In the US, new rules have been brought in to protect young players and could provide a vision of football’s future. In November 2015, the United States Soccer Federation introduced restrictions for all youth national teams and academies – they prohibit children aged 10 or under from heading during training or matches. Youngsters aged between 11 and 13 are allowed to head the ball during games but cannot exceed 30 minutes of aerial training per week, while headers per session is now capped at 20 per player.
“A lot of the data at the moment relates to adult football,” George Chiampas, the US men’s team doctor, tells FFT. “There isn’t a lot of research regarding youth football, but from the studies we’ve seen, it makes sense to protect youngsters, whose brains are still growing and could be more vulnerable to damage from heading footballs.”
As it stands, the US is the only one of FIFA’S 211 nations to have put protective measures in place. PFA chairman Gordon Taylor is keen for England to follow suit. “It would bring much needed focus on the issue of concussion in English football,” he tells FFT. “We’ve been talking to the FA about this matter, but they’re yet to act on it.”
Professor Antonio Belli is one of five experts who sit on the FA’S independent head injury panel. The group have put together new guidelines to advise clubs and players on the best practice for when players suffer concussions in matches, but the dangers of heading modern footballs still don’t appear to be a priority. “There’s a lot of anecdotal evidence out there, but I still don’t think there is any firm data to prompt these changes,” he says.
News of the developments on the other side of the Atlantic have been welcomed by Astle, but she stops short of calling for heading to be outlawed in the professional game. “We have never said that we want it banned – dad wouldn’t have wanted that – but the key is informed choice. If you go into a shop and buy a packet of cigarettes, you know the health risks. Not every player who heads a football for 15 years will get dementia in later life, but with one simple study we can inform current players of all the risks.”
Technology could offer a straightforward alternative to sweeping rule changes. Nauman believes it wouldn’t be difficult to design a relatively inexpensive piece of headgear to protect players from the effects of heading footballs. “It’s a fixable problem,” he says. “We could easily design a lightweight piece of protective gear for players that would absorb 90 per cent of the energy from headers.”
Wilkinson believes English football could learn a lot from American sport. “When I had treatment there, I saw the technology they are using,” he says. “If a player wears a piece of tech and can’t identify certain images, they’re told they shouldn’t be in the game any more.”
In the US, at least, the game is now heading in the right direction.