Sports Gazette

by sports journalism students at St Mary's University, London

Concussion In Sport Inquiry: Preparing For the Response

Posted on 26 November 2021 by Luke Collins

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Saturday 30th October 2021 marked a year since the death of Norbert “Nobby” Stiles. A legend at Manchester United, an integral part of England’s World Cup-winning squad, and an icon of the game.

However, the circumstances surrounding Nobby’s death mean that he has become a part of a wider conversation now occurring in football: how the sport treats brain injuries.

Stiles was diagnosed with dementia, the umbrella term given to neurodegenerative diseases that affect brain function.

Five of the England team that played in the 1966 World Cup final have subsequently been diagnosed with dementia: Bobby Charlton, Jack Charlton, Martin Peters, Ray Wilson, and Nobby Stiles.

Four, including Stiles, have since died.

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This year, the FA have done more to prevent brain injuries and limit future brain damage. But it has also been criticised for how it has previously dealt with these issues, as have other sports’ governing bodies.

There has been a focus on football and rugby. The Department for Digital, Culture, Media and Sport conducted an inquiry into the topic earlier this year.

It made several recommendations for the government to consider. And on Monday 29th November, the government is due to respond.

Concussion and CTE

The inquiry focused on how football and rugby report concussions and brain injuries.

It also reflected on the other ways sports cause brain damage which can subsequently lead to a player developing dementia.

The neurodegenerative disease that footballers typically develop is CTE – Chronic Traumatic Encephalopathy.

When Nobby Stiles died, his family donated his brain as part of the FIELD study, led by Professor Willie Stewart. The research revealed that CTE was widespread.

Brandon Boyd, Education Content Manager at the Concussion Legacy Foundation, explained the differences between concussion and CTE.

“Concussion is an acute brain injury caused by a violent shaking of the head.

“The resulting damage causes temporary changes to the way our brain functions. Most people recover within a month.

“CTE is a degenerative brain disease caused by repetitive blows to the head.”

Brandon referred to studies of boxers and American football players. 

Research showed that there was a greater risk of developing CTE if they suffered more impacts to the head. Symptoms of late-stage CTE include dementia.

“Concussion and CTE are often thought to be linked, but someone’s risk of developing CTE is much more strongly correlated with how many repetitive, subconcussive blows to the head they took rather than how many acute concussions they suffered.

“Individuals who have suffered concussions in the absence of repeated head impacts are rarely, if ever, diagnosed with CTE.”

The Concussion In Sport Inquiry – What it Uncovered

The inquiry demonstrated that in professional sport, there had been a failure to report brain injuries.

It was informed that the Health and Safety Executive (HSE), the government agency responsible for employee health and safety, left the governing bodies to decide how to treat injuries.

A memo from the HSE explained that the governing bodies and the rules determined how a sport is played.

They were responsible for making the sport enjoyable to play and watch while minimising injury risk.

The HSE considered the sports’ governing bodies as those who were best placed to make judgements on risks. They believed that they would make the required changes to rules and procedures when needed.

The committee was also told that brain injuries were unlikely to be reported. Under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, “they would not fit into the specified diseases or injury criteria.”

Parliamentary Under-Secretary of State for Sport, Heritage, and Tourism, Nigel Huddleston, also explained that there was no statutory requirement for sport to report injuries, unlike other sectors.

The DCMS stated: “We are astounded that sport should be left by the Health and Safety Executive to mark its own homework.”

An Underfunded Area of Research

Why though has more progress not been made to develop our understanding of brain damage?

Edward Pinches, the Senior Science Communications Officer at Alzheimer’s Research UK, linked the lack of research into neurodegenerative diseases in sport to poor funding.

“I think the funding for dementia research is behind other serious conditions.

“It’s sometimes hard to know what the links are between each individual sport and dementia. But that’s something that we are going to look to change.”

Brandon Boyd also pointed out that compared to other forms of dementia such as Alzheimer’s disease, CTE had not been as thoroughly researched or received the same funding.

“The most obvious explanation for this lag is connected to the history of CTE.

“CTE has been around in medical literature since a 1928 publication by Dr. Harrison Martland first identified the disease in the brains of former boxers.

“However, the medical community neglected CTE, and by 2005 there were only 42 cases confirmed in the global medical literature.”

What Has Been Done So Far?

The lack of previous research means that football is playing catch-up.

But recently, organisations have funded important research that has demonstrated how much more at risk footballers are from neurodegenerative diseases.

In 2019, the FA and Players Football Association commissioned Professor Stewart’s FIELD study.

His research found that a professional footballer was three and a half times more likely to die from neurodegenerative diseases than a member of the general population.

It also showed that defenders were five times more likely to experience some form of neurodegenerative disease. Forwards were three times more likely.

An update to the study this year revealed that even a short playing career doubled the risk of being diagnosed with a neurodegenerative disease. A long career increases the risk fivefold.

To help limit this risk, the FA has introduced restrictions on heading. A professional is limited to ten “higher-force headers” every week. Children under the age of 11 have been banned from heading.

Brandon Boyd believes this is a significant step.

“Given what we know about CTE, limiting professionals to a certain number of headers per week is certainly a positive step in risk reduction.

“Quantifying exactly how much they are reducing their risk and if ten is the correct number is difficult, but it is certainly preferable to an environment without limits.

“Age limits are a great way to reduce the risk of developing neurodegenerative diseases such as CTE. Our 2019 study of American football players found CTE risk doubles every three years of play.

“If soccer has a similar dose-response relationship, delaying the introduction of heading could prevent a lot of CTE cases.”

The Sports Gazette has previously written about why heading should be banned for young football players. Click here to read more.

Is It Enough?

However, some have criticised the new measures for not going far enough.

Much of the criticism has focused on the heading restrictions for professionals. As Brandon said, it’s difficult to quantify how much of a risk reduction these new measures will produce.

Professor Stewart went as far as to say that there was no way to know if the new measures would produce the required effect.

“To assess whether 10 high-force head impacts might make a difference, we have to wait 30 to 40 years.”

Former England captain Terry Butcher has called for heading to be phased out of football entirely

Edward Pinches also argued that further research was needed, but argued that the policy was a sensible one.

“Limiting the risk of heading in football seems a sensible precaution based on the evidence that they have so far. The FA seems to be making logical decisions.

“We’d like to see the football authorities and those making the rules also wanting to know the answers as well by getting behind our cause and funding new research.”

The recommendations made by the inquiry involved the government taking on a more proactive role in reviewing how sport treated concussion and brain damage.

Their response on Monday will indicate the direction football and sport more widely is going in.

The recommendations the inquiry made and the government response will be discussed in a follow-up article on the Sports Gazette.