Dementia in soccer: Why action needs to be taken to avoid long-term damage

A prominent Dublin neurologist has criticised the reluctance of sports organisations to take more precautionary action in relation to long-term brain injuries, something he fears may contribute to a growth in the number of people suffering from dementia and other mental health conditions in later life.

Prof Colin Doherty, who is a leading member of the Concussion Research Interest Group established six years ago by the department of genetics at Trinity College, Dublin, and the Clinical Research Centre in St James's Hospital, believes far more funding is required for independent medical research into the implications of participating in contact sports and related brain injuries.

In the case of soccer, he believes that the Field study, published in October 2019 by a team led by Dr Willie Stewart at Glasgow University, has established beyond any reasonable doubt an association between playing professionally and subsequently increased rates of neurodegenerative disease.

The report did not claim to establish a specific link with heading the ball, a commonly mentioned area of concern, but did find around 3½ times the rate of neurodegenerative disease in Scottish former professionals who had died over a 15-year period when compared with a large sample of the general public.

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Following the publication of the report, which was co-funded by the English FA and players’ union the PFA, the English, Scottish and Northern Irish football associations moved to ban children heading the ball in training.

Doherty sees the move as a good starting point.

“This is going to be the number one public health issue in the next 40 years because people are living with their cancers and past their heart attacks and living into the 70s or 80s, much more than we ever did,” he says.

No cures

The Alzheimer Association of Ireland puts the current number of people suffering with dementia here at 64,000, but says the number is expected to hit 150,000 by 2045.

“We have no cures for dementia, and so if there’s any way that we could impact on reducing the kind of things that expose people to the risks then we should be doing it now. For our generation’s sake and our kids’ generation’s sake,” says Doherty.

“In American football they just stopped tackling in high school until the game. So they don’t do it in training and that seems very reasonable; you could also consider certain types of tackle or going in with the head not being done in training, only in play.”

Doherty fears that the accumulation of subconcussive impacts, traumas that might barely register with a player at the time, will remain a major issue in contact sports despite improved awareness of more obvious head injuries, and he describes the force of the impact of a ball as being “very significant” in a variety of circumstances.

Doherty suggests “we need a kind of independent sports medical council, especially for the matches of high amateur level or professional level”, and believes national governing bodies should be more open to “some rule changes that would make it a little bit safer”.

“But I think the very minimum, the very easiest one, is to go down the American route which is to say, let’s reduce the overall dose by reducing the exposure to a head injury in practice and then play the same game at the weekend. That seems to be to the immediate way. Although, I’m not the guy to make that decision.”

Guidance

Dr Alan Byrne, who as adviser to the FAI, kind of is that guy, says that while the organisation here takes the issue very seriously, the move by the English, Scots and Northern Irish went beyond what has been recommended by Uefa, whose guidance has, he suggests, been followed by all but three member national associations across Europe.

Byrne says the incidence of children heading the ball has been found to be very low. He agrees that more research is required, but says the huge body of work undertaken so far has not established a link between heading the ball at any age and an increased incidence later of conditions like Alzheimer’s, Parkinson’s or chronic traumatic encephalopathy (CTE).

Uefa discourages heading drills in training, suggesting they be “reduced as far as possible, taking into consideration the heading exposure at matches”, something Doherty sees as “a positive”. The federation does not endorse a ban, although its guidelines are the recommended minimum of action to be taken, with associations left to decide whether to go further locally.

In relation to the issue of dementia among former professionals, Byrne describes Field as valuable but having limitations. He characterises it as another part of a much wider debate.

“Obviously this is an area that is of huge importance to us as an association, but there was no evidence in the Field study to suggest that heading the ball was the cause of the incidence of neurodegenerative disease. There’s no evidence. I think if you read the study carefully, it specifically says that that link has not been made.”

Asked what he thinks does account for the dramatically increased rates of dementia, he says he does not know and that this merits further investigation.

“I work in general medicine also and I have patients with dementia, and it is absolutely tragic to see somebody disintegrating in front of you. But I feel it’s important to strike a balance. I don’t want in any way to come across unsympathetic to people who’ve had relatives, whether footballers or not, who suffer with dementia, but we need to work with the science. It is important that the decisions we make are proportionate in relation to the evidence.

“The link between a particular activity and the outcome needs to be proven, and I think we’re still a good bit off that in terms of proving that. I absolutely want us to go on looking, but we have to be careful.”

Studies

Doherty says there will never be actual “proof”, and that the sort of prospective studies (identifying young players then monitoring them over a very long period) that might provide more conclusive evidence would take decades to complete. One, started 20 years ago by the English FA, fell apart when none of the players progressed to the professional ranks.

While the debate continues and ways of mitigating the issue through further changes to the weight or pressure of balls or other revised rules, a growing number of more recently retired players have expressed concern about their future health.

Kevin Doyle, who stopped playing in 2017 on medical advice after getting to the stage where he felt unwell whenever he headed the ball, says he gets asked about it a lot.

The former Republic Ireland striker says he feels very well now, but he has visited both the FAI and English FA to talk about his experience. Based on what he has been told, as well as his own sense of the way the game has changed, he does not support a ban on heading, even for children.

“It’s a totally different scenario now,” says the 37-year-old, who reckons he was concussed at least twice in every season of his career but never required to observe anything like the sort of protocols in place now until he went to play in the MLS.

“I’m not an expert but in my opinion most of the damage was done, or is done, when people go back and head or get kicked or whatever when their brain is still bruised and they haven’t recovered from whatever bang they got.”

That, he says, and during the sort of long, repetitive training sessions he used to do to perfect an aspect of his game he enjoyed back then but subsequently came to hate.

“When we were doing heading practice we could do an hour of this cross and head, cross and head. How many must there have been when you added them up over the years? Where as that is not the case now. That’s not done from my knowledge. No one is stupid enough to do it, and football in general is not played in the same way.”

Crossing the ball

There is an element of truth to that, although the issue is not at all straightforward and his impression that there are far fewer headers per game now is certainly not supported by Fifa research based on World Cups since 1966, which suggests there are actually more. He is probably right, however, that young players do not view things quite the same way.

"When I was a kid growing up I was trying to be Niall Quinn and Tony Cascarino, " he recalls, "so it would be my brother crossing the ball for me so I could head it. I don't think there are too many kids trying to be Niall Quinn or Tony Cascarino these days. They all want to be Messi."

FORMER PLAYERS AND DEMENTIA

Former Shelbourne striker Ben Hannigan suffered from dementia for more than five years prior to his death, aged 80, at the start of this month. Like many family members of footballers in similar circumstances, his daughter Kim remains unsure how much of a part, if any, her father's career in the game played in the illness that afflicted him towards the end of his life.

“Although he was a striker I don’t think my father actually scored many of his goals with his head, and I’m told it’s not something that he would have been particularly known for during his career,” she says.

“In training, though, he would have practised it a lot, and there does seem to be the possibility that heading the ball all those years was a contributory factor to his condition.

“I certainly think that it is something that we need to know more about. I think it is really important that there is more research into this area because at the moment we can’t be sure, we’re just left to speculate.”

As players from the 1960s age, clusters of cases from famous British teams like Liverpool, Manchester United and the World Cup-winning England team of 1966 have emerged.

The deterioration in his final years of former Ireland manager Jack Charlton was recently highlighted in the deeply affecting film Finding Jack. In it his wife, Pat, also admits to being uncertain of the extent to which heading the ball contributed to his illness.

“Whether it was heading the ball as much as he did we don’t know. But it’s like boxing, getting hit in the head; nobody can actually prove that it is. He enjoyed his football, though. Would you take that away from him? I don’t think so.”

Concussions went largely unrecorded at the time, and symptoms were generally ignored. Yet routine heading of the ball remains a major focus for many players of that and subsequent eras, with Hannigan's team-mate Jackie Hennessy articulating a widely held view that balls these days are "balloons" by comparison with the one used then, especially when they were wet.

One rare case of a direct connection having been officially declared is that of England striker Jeff Astle, who died in 2002 aged just 59. A coroner ultimately found that the repeated minor traumas he had endured as a professional had been a key factor in his mental decline and death.

Hannigan's Shelbourne team-mate, former Ireland international Tommy Carroll, is reported to have suffered with dementia prior to his death last August and at least one other member of the club's 1962 title-winning side is understood to be living with the condition.

The man Carroll replaced in the Dublin club's team, Tony Dunne, also passed away last year, with the 78-year-old European Cup winner with Manchester United regarded as one of the great players of his generation.

Though he died of Covid-19 having been admitted to hospital after a fall at home, Dunne suffered with dementia over the last 12 to 18 months of his life.

After a career in which he was admired for his willingness to put his body on the line during games and play through injuries, his daughter Lorraine suggested after his death that her father seemed to believe football had been a contributory factor.

In interviews she recalled a night towards the end of his life when the family returned to Old Trafford. “Whilst Dad was looking over to the pitch, he turned to us and said ‘this is where I hurt my head.’ He wanted to leave. The whole day was sort of overwhelming for him.

“His life was over as far as he was concerned because he couldn’t swing a golf club or kick a ball. He didn’t want to be here. He used to plead with my mum to end his life. He was frightened. You could see he was tormented and the pain in his eyes.

“He became aggressive. He was throwing furniture, kicking, biting. He would pull the drawers out and cupboard doors off. My dad was a very quiet man, as they used to call him. He was all about respect. He wouldn’t behave in a manner like that.”

Her mother, she said, believed the problem was rooted in the regular bangs to the head he had received through his playing days, and while Dunne does not seem to have clearly articulated the belief, Lorraine feels he suspected it to.

“He knew, to pass a comment like that,” she said. “We all looked at each other, shocked. Why would a man suffering dementia refer to a football pitch as somewhere he hurt his head?”