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Brain injury

Brain injury in football – heading for trouble?

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Ipek Tugcu - specialist brain injury lawyer and Southampton fan

Football fan and specialist brain injury lawyer Ipek Tugcu has become a leading analyst of the concussion in sport debate. Here, she discusses the crucial issue of player safety with NR Times.

Whether you’re a football fan or not, you’re likely to have seen that the sport has recently been in the headlines for all the wrong reasons.

The focus has been on how football has dealt with the increased risk of neurodegenerative disease suffered by professional players. The quick answer? Not well.

I initially became involved in this campaign as I was a football fan and also work as a brain injury lawyer, representing those harmed by medical negligence or an accident.

Attempting to change any sport is a sensitive matter. Now more than ever, fans rely on sports as a means of escape from their busy lives.

People invest a lot into their favourite team, and the idea that tradition could change often causes immediate uproar. So it’s important to look at the facts, and to understand what the issue is and how the sport could evolve, to allow it to safely continue.

So what is the issue?

While it may just be hitting the news now, none of this is new. For decades, campaigners have raised concerns about the increasing number of professional players diagnosed with neurodegenerative disease, namely dementia.

Of course, neurodegenerative disease can affect anyone, but a worrying correlation has been apparent in the sport.

One of those players affected was West Brom legend Jeff Astle, who died in 2002, aged 59. His death was due to chronic traumatic encephalopathy (CTE) – a progressive, degenerative brain disease usually suffered by athletes with a history of head injury, such as multiple concussions.

Sadly, his situation is not an anomaly, and a growing number of former footballers have been diagnosed with dementia, including Gordon McQueen, Sir Bobby Charlton and Nobby Stiles.

So what exactly are the risks?

In October 2019, a research study commission by the FA and PFA (the “FIELD” study – Football’s InfluencE on Lifelong health and Dementia risk) revealed that former professional footballers were 3.5 times more likely to suffer from neurodegenerative disease than the general public.

Within this, former footballers were 5 times more likely to develop dementia or Alzheimer’s and twice as likely to have Parkinson’s.

These statistics are alarming, and working in the field of brain injury – we know the widespread devastation that such conditions cause, not just to the individuals diagnosed but to their friends and family, their local community and the NHS, who are often left to pick up the pieces and care for them.

The reality is that brain injuries, by their nature, cause significant administrative and financial pressures on individuals and authorities caring for the patient. The sporting world needs to take on the burden of finding solutions to problems they have created, before the younger generation is put off sport for good.

So what is it about football that puts players at increased risk? Whilst the FIELD research study didn’t pinpoint the exact aspect, research tells us that:

  • It’s nothing to do with the argument that ‘the balls back in the day were heavier than the current, modern ones’. This is an incorrect misconception which has been debunked. The old leather balls and the new synthetic ones both weigh around 15oz. Whilst the older balls were heavier when wet, this means they would also have been slower so would have had less of an impact when hitting a player’s head. As such, today’s players face the same risks as footballers from decades ago.
  • Subconcussive hits may be the main culprit. People often focus on concussion in sport, but it’s easy to forget that even those blows to the head that don’t formally cause concussion (i.e. are subconcussive) will impact the brain. In respect of football, players suffer most of their subconcussive blows during training, when practising heading. This type of training can usually mean hours every week of repeated hits to the head. Multiply this by the likely duration of their career, and a bleak picture emerges of the extent of trauma suffered to the head.

Despite the above, the current rules in football have not changed.

Whilst injuries, including head injuries, are part and parcel of any sport, it doesn’t negate the fact that players should be protected from known risks. It’s reckless and not to anyone’s advantage to ignore the research.

There’s also the legal side to this. Professional footballers are employees merely doing their job and, as with anyone in this situation, their employer has a duty of care to take reasonable steps to protect them from foreseeable harm.

Ignoring known risks will only cause a headache for governing bodies in the future, making them vulnerable to legal claims against them for ignoring the known dangers and failing to establish and follow proper protocols. You only have to look to the NFL to see that this is not a far-fetched prediction.

So what’s the solution? Do we ban all forms of heading in football? What about the fact that footballers choose to play the sport, and with that comes an element of risk – do we just have to eliminate all potential injuries from the sport?

The truth is, the authenticity of football does not have to be compromised in order to protect a player’s health. There have been a number of proposed enforcements, however as a fan and campaigner, temporary football concussions has been one option which I hope could really make a difference.

As of 6th February 2021, the Premier League became the first in the world to introduce a trial for permanent concussion substitutes. So, what exactly does it mean – and how does it compare to the campaign for temporary concussion substitutes?

The current trial means that where a head injury has occurred, or is suspected, the injured player’s club can make a concussion substitution. This means:

  • They can substitute that player, even if they have used up all their normal substitutions. The player will be removed from the pitch and sent for head injury assessment in a private room. The substitution is permanent – once the player is off the pitch, they cannot return to the match, even if the assessment finds that they are absolutely fine.
  • To ensure a level playing-field, the opposing team is afforded an additional substitution at the same time too
  • A team is allowed two concussion substitutes, per match

The intended aim is to put the player’s health at the forefront and ensure that this is the priority, over team tactics.

At the moment, there’s a fear that players aren’t being substituted for proper head injury assessments because the club is focussed on their match strategy. The trial hopes to encourage clubs to be reassured that they will not be at a disadvantage by having their player assessed for a potential head injury.

Temporary substitutions are similar, but crucially allow a footballer to return to play if they are deemed safe enough to do so. In this case, the player would be temporarily replaced by a teammate, but then would be able to resume play if they had the all clear.

The concern is that permanent substitutions don’t encourage players, or clubs, to proactively engage with the trial – because they know that starting this process will automatically rule that player out for the rest of the match, regardless of the outcome of their medical check.

So you’re left with a situation where the manager needs to make a quick decision on the spot as to whether they’re willing to lose that player for the remainder of the match.

Even for the most caring manager, this puts them in a position of choosing team tactics over player safety and we’re back to square one.

A perfect example of this happened in a recent FA Cup match, where West Ham’s Issa Diop suffered a nasty head collision. He played on, whilst clearly struggling, until finally being substituted at half time.

Of course, we don’t know why a decision was not made at the time of the injury to engage with the trial – but it makes you wonder whether not wanting to lose their player factored into the club’s decision and they decided to chance it to see if he could be safe to play on.

Temporary substitutions offer a win-win situation for clubs and footballers.

Teams can be reassured they won’t be at a tactical disadvantage, as the substitution could just be temporary, and players can be reassured that their health is made a priority and they can undergo a thorough head injury assessment privately.

Doctors will be well-versed in the mantra ‘if in doubt, sit them out’ – so the risk of putting a potentially injured player back on the pitch is minimal.

This continues to be an ever-evolving situation affecting footballers here and abroad. It will be interesting to see what permanent steps, if any, are taken by the Premier League and other leagues across the world.

Of course, the issue of brain injury mismanagement in sport isn’t just limited to football. It’s my hope that a balance can be achieved between protecting players, reassuring the new generation and still allowing fans to experience the thrill of the sport as they have always known it.

* Ipek Tugcu is a Senior Associate in the Adult Brain Injury team at Bolt Burdon Kemp and an avid Southampton fan. She is a well-known campaigner for brain injury in sport, particularly football, to be taken more seriously.

Twitter: @Ipek_Tugcu

Brain injury

‘I’m sorry for handling the steering wheel with buttered fingers’

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As he continues to come to terms with the loss of his ‘ex life’ and learns to celebrate the 21st birthday of his new self, The Brain Damaged Baron reflects on the comfort blanket of support from those close to him, while struggling with the loss of vanishing friends

 

Let’s get straight down to business.  The salient truth is that one day, the life I once knew came to an end. Yep, gone, cheerio, toodle pip.

It is an ex-life. It has ceased to be, I trotted off this mortal coil in order to push up some buttercups. Is it buttercups? I forget. 

It was so very difficult, sometimes impossible, to comprehend that all I knew had gone. That sentiment only increased over the years and there have been 21 of them. Twenty-one long years.  My new life has matured and is now old enough…

To vote – when it remembers to.

To drive – it can’t, partial blindness caused by the brain injury would make driving an absolute lottery.  That and the complete lack of spatial awareness. After all, I can’t walk down the street without colliding with lampposts. I wouldn’t be safe in a bubble wrapped bumper car. I’m not sure the roads of the UK are ready for me just yet.

To drink alcohol – it can’t, epilepsy denied that pleasure. Due to medication, I feel half-drunk most of the time anyway. Without alcohol, I have the memory of a goldfish with Alzheimer’s disease. I hardly need the odd libation to wipe what recall I do have. 

To have sex – if I can stay awake long enough. I’ll say no more. It was all I could do to prevent myself typing ‘stay up’ long enough. Ooh-er, Mrs!

And it’s now old enough to know what the hell happened to me.  And is still happening right up to this very day.

That’s the nature of a bang on the bonce; confusion.  

Massive disorder in my mind, incomprehension shadows me like the gloomiest raincloud preparing to unleash a deluge of perplexity. I know it’s there, it’s always there. The monkey on my back, the albatross overhead, the angry weasel with a chip on its shoulder.   learnt to live with it. 

That and the ability to invent nonsensical idioms. It’s a gift.

However.

Back in the day, long before I became 21 again, it began.  The curtains were closed, slammed shut. Well, to be fair, they were curtains, not so much ‘slammed’, but more ‘flopped’.  They needed opening, I had to let the day begin.  And commence it did, as the flaccid curtains were swept aside and the hard graft started.

While I was hurting, while I was struggling, while I was learning, there were other people around. There still are, every day. It’s just a question of tenses really.  

Watching, witnessing, feeling my pain. Either on the side-lines or directly involved, family, friends, all observing the effects. Mostly it was no spectator sport, it was grim viewing, if I am honest. And still they remained, standing by with a collective arm outstretched.  

Twenty-one years later and it’s still there. A comfort blanket, a safety net cushioning the unavoidable falls.

It’s a whole new world out there, and that world has a habit of biting back. Sometimes it is just a nip, although occasionally, it’s like a bite from a hungry shark. And those nibbles come thick and fast. Each bite eroded away my former self and ate away, no pun intended, at the life that had sadly departed.  All the while…

Watching, witnessing, feeling my pain…

There are so many bites that they all seem to merge into one. Remembering can be exhausting beyond belief. I had never thought it possible to get so drained, so shattered simply from attempting to recall what the day is.  

Another aspect of my life that my previous self had taken for granted. There was never any reason not to. I was a 25-year-old man and it didn’t seem a lot to ask to remember where I kept my keys. It was never a conundrum.  

However, after the injury, I could then forget where I kept my pants and socks, let alone my keys. Not when I was wearing them, obviously; my pants and socks that is, not my keys.  

And with the exertion of something as basic to a human being as ‘thought’ came the inevitable headaches. The first to strike shook me to my very core. It smarted, just a tad.  They continue to this day, bless ‘em. 

Almost a year after the old brain took its battering and continued to fight the good fight, epilepsy was thrust into my life. The unwanted gate crasher causing havoc with every appearance. A lightning bolt from the deepest blue. Body spasms, unconsciousness, confusion, memory lapses, post seizure headaches that make the usual head pains seem like old friends.  Well, it keeps me on my toes.  And still…

Watching, witnessing, still feeling my pain. The outstretched arm remained, absorbing the anger and feeling my frustration. 

Fatigue and apathy soon entered the fray. More undesirable visitors cluttering an already overloaded brain. They pushed aside my old friends ‘eagerness’ and ‘concentration’ as ‘alertness’ looked on with all the subtlety of a slightly annoyed bricklayer wielding a sledgehammer. Oh, he had anger issues too.

The passage of time was a cruel mistress. Particularly when my addled brain was struggling to establish some form of normality… whatever that may be.  

My life in its entirety had altered beyond recognition. Epilepsy could now strike without warning at any given moment, throwing the day into chaos. Fatigue that plagued almost every aspect of my life began to throw up barricades.  

It was hard to live with what I had become.  To live in the present and not rely on the past.

And still they watched, witnessed, felt my pain. And for some, it was too much, too difficult, too much like hard work. 

Relationships ended and friendships broke down. Ultimately, people vanished. They had their reasons, I was never told what they were, but I’m sure they had them. Occasionally I had the courtesy of an invented tissue of lies that possibly salved their own conscience, but only served to batter my own into submission.

Relationships with everyone in my life, friends, new acquaintances, and even the odd member of my family, seem to be based on the flip of a coin. 

Should a ‘Head’ land on terra firma and whatever my brain throws into the mix, they’ll hang around. Should a ‘Tail’ drop gracefully to the ground and they’ll turn that tail and run for the hills.  And that’s how it’s been since the day I landed on my cranium with one hell of a thud.  But wait a moment here…

I like to think I’m not a stupid man, I pride myself on it in fact. I’m 46-years-old now, time is marching on relentlessly like a runaway train with only one destination.  

I’m married to my best friend, a couple of children have their place in my life and I’m still learning more about my own limitations and abilities. Only one thing has remained constant throughout the journey that became my second shot at this rollercoaster we call ‘Life’. That damn scar on my brain still throws its weight around whenever it fancies a bit of a giggle. And thus…

I still forget things with frightening regularity.

I can’t control my emotions like I should.

Background noise irritates me to the point of exasperation.

I still invent idioms like a ferocious aardvark with a knuckleduster.

I may have a seizure with varying degrees of severity at any given moment.

Fatigue is a pest that simply won’t leave me be. And sleep is my panacea.

I can’t socialise like I once could.

I can’t drink, I can’t drive.

I am no longer the ‘me’ I once was. And do you know what? I no longer care. I wouldn’t change one God damned thing.

I throw out these statements with gay abandon, almost on a whim.  The fact remains that while I was coming to terms with the throwaway facts, those people close to me WERE watching, they WERE witnessing and they WERE feeling my pain.  

For instance, let’s start at the very beginning. I was in a coma in hospital. Essentially, I was asleep, just for a smidgeon longer than usual. I always was a lazy sod. While I slept, my family and friends sat at my hospital bedside wondering whether I would live or die. I had it easy, I really did. I still do.

The first epileptic seizure and every single one since sees my good self disappear into another world for however long, while whoever is there can only watch, wait, and worry.  Again, I repeat, I have it easy.

I have a wife I adore. The lady who came along and turned out to be the missing piece in my jigsaw. Who knew? The rock to my roll, the milk on my cornflakes. Much like my friends and family who were there long before that missing piece arrived, she tolerates the moods and the headaches.  She lives with the forgetfulness, the now thankfully muted anger, the annoyances, etc. They’re all part of just another day.

Twenty years of watching and worry. Good grief, I’m so sorry for putting you all through this journey, none of you asked to be passengers, you really didn’t. You still don’t, you never so much as complain. I certainly didn’t want to be the driver and I’m sorry for handling the steering wheel with buttered fingers…

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Brain injury

Sleep problems ‘can be worse with mild TBI’

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Sleep disorders are more prevalent among people with mild traumatic brain injuries (TBI) in comparison to those with more a severe diagnosis, new research has revealed. 

In the study, the links between TBI and sleep problems were strengthened further, with people with TBI shown to be up to 50 per cent more likely to develop insomnia, sleep apnea and other sleep disorders than people who have not been injured. 

And in a significant outcome, the association with sleep disorders was stronger amongst those with mild TBI than in the case of serious injury. 

The research also showed that the risk for sleep disorders increased for up to 14 years after a brain injury – showing the need for the impact of TBI to be assessed in the long-term, said the research team from the University of California. 

“Clinicians should ask TBI patients about their sleep and they should follow that up,” says study investigator Yue Leng, assistant professor in the university’s Department of Psychiatry and Behavioral Sciences.

Data was analysed from 98,709 Veterans Health Administration patients diagnosed with TBI, alongside an age-matched group of the same number of veterans who had not received such a diagnosis. The mean age of the participants was 49 years at baseline, and 11.7 per cent were women. Of the TBI cases, 49.6 per cent were mild.

Researchers assessed a number of sleep disorders, including insomnia, hypersomnia disorders, narcolepsy, sleep-related breathing disorders, and sleep-related movement disorders.

During a follow-up period that averaged five years but ranged as high as 14 years, 23.4 per cent of veterans with TBI and 15.8 per cent of those without TBI developed a sleep disorder.

After adjusting for age, sex, race, education and income, those who had suffered a TBI were 50 per cent more likely to develop any sleep disorder compared to those who had not had a TBI. 

The association with sleep disorders was also found to be stronger for mild TBI than for moderate to severe TBI which, say the research time, might be due to differences in the brain injury mechanism.

While the study was conducted with veterans, the research team expected to find an increase in probability of sleep problems in those with PTSD. 

“But actually we found the association was pretty similar in those with, and without, PTSD, so that was contrary to our hypothesis,” says Leng.

The researchers could not examine the trajectory of sleep problems, so it could not be concluded whether sleep problems worsen or get better over time, she adds.

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Brain injury

Women ‘more likely to have long-term issues after concussion’

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Women may be at increased risk of long-term physical and mental issues after a concussion, a new study has revealed. 

In analysis of 2,000 people who sustained a head injury, women were found to be more likely than men to still have some symptoms a year later. 

These included memory and concentration problems, alongside headaches, dizziness or fatigue. 

Women between the ages of 35 and 49 typically had worse symptoms than both younger and older women, the research found. 

The study revealed that in other traumatic injuries, men and women’s recovery times were similar – the main area of disparity was in brain injuries.

While this research cannot answer the question as to why this happens, says lead researcher Professor Harvey Levin, from Baylor College of Medicine in Houston – it is possible, he says, that chronic inflammation in the brain tissue or hormonal influences play a role.

The brain has receptors for oestrogen, and previous research has indicated that women who sustain concussion at certain times in the menstrual cycle tend to have a slower recovery.

It also builds on previous research which has also pointed to sex differences in concussion recovery. 

Writing an accompanying piece to the study, which was published in JAMA Network Open, Martina Anto-Ocrah, an assistant professor of emergency medicine and neurology at the University of Rochester Medical Center, says it strengthens the case that women’s slower recovery is related to concussion. 

“We expect most patients to recover within weeks,” Anto-Ocrah says, adding that about 90 per cent have largely recovered within three months.

But in the study, women did have higher rates of depression and anxiety diagnoses before the concussion, compared to men. And those are risk factors for prolonged concussion symptoms, Anto-Ocrah adds.

However, the researchers accounted for depression and anxiety, and those diagnoses did not seem to explain women’s more persistent symptoms.

Some women, Anto-Ocrah says, encounter scepticism when they tell their doctor they are still having concussion symptoms many months after the injury.

“This is additional proof that it’s not all in your head,” she adds.

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