Heed the baal?

Back in February I wrote an article about Lloris Karius which focused on the after effects of concussion, not just in the Champions League final but on his career.

One of the things I found out, was that concussion can lead to more severe brain injuries, as well as the development of dementia.

This insight had me worried at the sight of Fabian Schar being pole-axed by a boot to the face from everyone’s’ favourite Man Utd player, Ratus Ibericus – aka Bruno Fernández – because it was potentially his second concussion in quite a short period of time.

It also had me wanting to find out a bit more about dementia itself and how it affects footballers, as I recall there being quite a lot of attention being given to the subject a while ago but it seems to have died down more recently.

Dementia is caused by damage to brain cells which then interferes with their ability to communicate with each other. When brain cells can’t communicate normally, thinking, behavior and feelings can all be affected. But what causes the damage?

Unfortunately for myself and quite a few others who frequent The Mag, the biggest risk factor is age, but another obvious cause and highly relevant to footballers, is repeated blows to the head. Chronic traumatic encephalopathy (CTE) is a brain condition thought to be linked to repeated head injuries and blows to the head. It slowly gets worse over time and leads to dementia. You’re most at risk if you regularly played contact sports, such as football, boxing, martial arts and rugby.

A month ago, the Karolinska Institutet in Sweden, published the results of an in-depth study comparing the health records of 6,000 elite footballers and more than 56,000 non-footballers between 1924 and 2019.

They found that among male footballers playing in the Swedish top division, 9% were diagnosed with neurodegenerative disease (ie dementia) compared with 6% of the control sample. They found that outfield players had a 1.6 times increased risk of Alzheimer’s and other forms of dementia than the wider population – but goalkeepers had no increased risk. The obvious conclusion being that it was heading the ball that made the difference.

These findings follow a 2019 study in Scotland which concluded that ex pro footballers were 3.5 times more likely to develop dementia and other serious neurological diseases. Little wonder then that Dr Adam White, head of brain health at the Professional Footballers’ Association, has called for the Industrial Injuries Advisory Council to “to recognise dementia as an industrial disease”.

It’s clearly a serious issue – so what’s been done about it?

Concussion substitutions seem to be a sensible option to protect players and these have been trialed. The FA wanted to trial temporary concussion subs, such as you have in the AFL, but this was rejected by the International Football Advisory Board. The system of permanent substitutions has been ongoing for two years, with a maximum of two per team in any match, but has come into criticism from various quarters – mainly due to the reluctance of managers to permanently substitute a player leading to them staying on the pitch then having to be subbed later as the after effects become more pronounced.

It’s a bit late reacting to an incident during a game though, so what else has been done? A lot of attention has obviously been focused on heading the ball and especially for younger players. Both the PFA and the FA have issued advice on the subject.

In February 2020, the PFA gave this heading guidance for under-18 players:

No heading in training in the foundation phase (primary school children)

A graduated approach to heading for children in the development phase, including those playing in under-12 to under-16 teams

Reduction of under-18 heading drills to take into consideration the heading exposure in matches

The lowest pressure should be used when inflating footballs for both training and games

This was followed in 2021 by the FA’s “guidance recommendations” for the professional game:

A maximum of 10 higher force headers are carried out in any training week. A higher force header includes those following a long pass (more than 35m) and those from crosses, corners, and free kicks

Players practise technique using thrown passes, as it is suggested that this leads to lower peak accelerations
clubs develop player profiles that take into account gender, age, position, the number of headers per match and the nature of these headers

Club staff work with players following each match to ensure players have adequate recovery time following heading exposure

In England, the FA is trialing banning Under 12s from heading the ball in certain grassroots competitions and leagues. If successful, it will apply to the International Football Association Board for a law change to remove heading for under-12s altogether but campaigners have called for a complete ban on children heading the ball regardless of the level of competition.

Dawn Astle, daughter of Jeff Astie, is the project lead for neurodegenerative diseases in football at the Professional Footballers’ Association and pointed out in a Guardian article last year that, “Going into the 2022-23 season, all professional clubs must incorporate the appropriate heading guidelines into their training regimes. Their responsibility extends to their youth, women’s and men’s teams.”

Her father’s death was ruled by a coroner as being due to an industrial disease (CTE) brought on by repeated heading of the ball. Jeff was renowned for his heading ability and I remember a photo in one of the daily newspapers in 1970 which claimed to show him bursting the ball with a header during a game!

It’s obviously a tricky problem for the powers that be. They have a duty of care to the players and once certain risk factors become known, they have to show they have taken all reasonable measures to mitigate them.

We have seen examples of litigation, such as smokers suing tobacco companies and even a lady (in America – where else?) who sued the manufacturers when she set the cruise control on her camper van so that she could go to make a cup of coffee – and it crashed! She won her case!!

I can hear the cynics now. We’re being mollycoddled. The world is woke – it’s the nanny state gone mad. The litigators have scared the football authorities witless. What next? No kicking the ball in case it causes in-growing toenails?

As the Bard of Avon might well have said: “To head or not to head, that is the question. Whether ‘tis harder on the mind to suffer the crosses and corners of outside lefts and rights. Or to duck and dive against a sea of high balls, And by dodging, miss them?”