Concussions and Brain Injuries in Football

The BPL (and the FA) has just announced new rules and policies governing head injuries.  The question is whether those new rules are adequate or whether the pre-existing state of denial will just continue.  Because this article must refer to both American football and real football, I will do my best to keep it clear as to which I am talking about at any particular time. (Also, because I am an attorney, I will cite my sources.)

I am particularly concerned about this issue because, if the NFL’s experience is any indication, the consequences of this issue could be quite costly to English football, including, of course, Southampton FC.  More importantly, brain injury can cause devastating consequences to its victims and Southampton FC has a responsibility to protect its players and, more importantly, the children at its academy from the lifelong problems that can arise from brain injuries.

The new rules were announced Tuesday on the official BPL website:

(http://www.premierleague.com/en-gb/news/news/2014-15/aug/premier-league-announces-new-medical-rules-and-policies-for-head-injuries.html)

I have been unable to find the official new rules on the web.  The BPL’s announcement of the new rules included the following bullet points:

• Premier League Rules making clear that when a serious head injury is suffered on the pitch (in matches or training) that the ruling of the doctor/medical practitioner is final.
• The role of "Tunnel Doctors" (it is a new requirement for all Premier League matches to include a Tunnel Doctor) will include supporting the home and/or away team doctors in helping recognise the signs of concussion.
• Making it mandatory for all Premier League medical staff to carry the Concussion Recognition Tool
• Annual baseline testing should take place on each Premier League player

The FA’s website provides more detailed guidelines (http://www.thefa.com/my-football/head-injuries-in-football ) although I still can’t find any formally written up rules.  Perhaps they just have not been released yet or, as an American, I can’t properly search English web sites.

Of particular interest is this statement from the BPL announcement, attributed to Dr. Gary O’Driscoll, FA Head of Sports Medicine:

… we wanted to make sure that the players, the managers, the coaches, the medical teams, the media and the parents, everybody is aware that although it's fortunately a very rare injury, it's something that must be managed appropriately and safely. 

This claim of rarity is, of course, nonsense.  Concussions are not rare injuries in sports and not just in American football.  In fact, as far back as 2002, a Canadian study (Concussions Among University Football and Soccer Players by J. Scott Delaney, MDCM, Vincent J. Lacroix, MDCM, Suzanne Leclerc, MD, and Karen M. Johnston, MD, PhD) suggested that concussions were quite common in both American football and football:   

 

Of all the athletes who returned completed questionnaires, 70.4% of the football players and 62.7% of the soccer players had experienced symptoms of a concussion during the previous year. Only 23.4% of the concussed football players and 19.8% of the concussed soccer players realized they had suffered a concussion. More than one concussion was experienced by 84.6% of the concussed football players and 81.7% of the concussed soccer players. Examining symptom duration, 27.6% of all concussed football players and 18.8% of all concussed soccer players experienced symptoms for at least 1 day or longer.

( http://www.reactcanada.org/FR/resources/articles/sport_specific/CIAU_concussions-DELANEY.pdf )

A 2014 study of American female high school soccer players (Concussion among Female Middle-school Soccer Players by O’Kane, Spieker, Levy, Neradilek, Polissar, and Schiff) yielded similar results, albeit with a lower frequency.  According to that study, 13% of the players suffered concussions during the course of the season.  (http://www.ncbi.nlm.nih.gov/pubmed/24446018 ) There is no way to know for sure why the rate was lower.  Possibly the difference between concussions and symptoms of concussions is part of the explanation.   Even so, 13% is not low enough to make the injury rare.

Rarity is certainly not the result found in a literature review by Dr. Tom Scheizer in the journal “Brain Injury.”  Instead:

Examining research papers that studied the incidence of concussion in soccer, he found that concussions accounted for 5.8 per cent to 8.6 per cent of total injuries sustained during games. One study found that 62.7 per cent of varsity soccer players had suffered symptoms of a concussion during their playing careers, yet only 19.2 per cent realized it. Another found that 81.8 per cent of athletes who had suffered a concussion had experienced two or more and that players with a history of concussion had a 3.15 times greater odds of sustaining another one than those who had never had a concussion. One study found concussions sustained during soccer accounted for 15 per cent of the total number of concussions in all sports. In particular, girls’ soccer accounted for 8.2 per cent of sports-related concussions, the second highest sport after football.

(http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2014/20140210_hn )

Whatever, the rarity, taking steps to deal with the problem is, of course, a great idea.  However, it is questionable whether the new rules are enough and whether they will even be enforced.  After all, the rule was pretty clear last year.  According to the 2013-2014 BPL Handbook:

O.9. Any Player, whether engaged in a League Match, any other match or in training, who having sustained a head injury leaves the field of play, shall not be allowed to resume playing or training (as the case may be) until he has been examined by a medical practitioner and declared fit to do so.

Hugo Lloris was definitely not cleared by a doctor before he was allowed to continue playing even after being knocked unconscious in a game with Everton last season.  Perhaps, the excuse was that he never officially left the field of play.

While all of these changes are improvements, there is at least one glaring loophole.  The BPL rules only apply to a “serious head injury.”  Since concussions are under diagnosed and most players don’t want to come off the field, these rules seem likely to lead to a rash of not-so-serious head injuries this season.  Players who bump heads will, no doubt, insist that they were not injured and are just fine.  Very likely we will no longer see unconscious players returning to the game, but there might be no change in what happens with lesser head injuries. 

This is particularly true since repeated brain trauma is an inherent part of the game.  There is good reason to believe that repeatedly heading the ball causes brain damage.  The high school girls study mentioned above found that 30.5% of the concussions were caused by heading the ball.

Moreover, it is not just concussions that are a problem.  Repetitive head trauma that can occur simply from heading the ball appears to be a problem in and of itself. Since I am not a medical expert and do not intend to pay the outrageous fees that are required to access medical journals I would not understand, I cannot go into more detail, but here are a couple more links suggesting that real and possible permanent brain damage is caused by repeated head trauma that did not rise to the level of a diagnosable concussion:  (http://www.momsteam.com/sub-concussive/sub-concussive-hits-growing-concern-in-youth-sports?page=0%2C1 ; http://consumer.healthday.com/cognitive-health-information-26/brain-health-news-80/heading-soccer-ball-can-damage-brain-study-says-684615.html)  The International Rugby Board has some useful information, as well: (http://www.irbplayerwelfare.com/pdfs/Concussion_Guidance_for_the_General_Public_EN.pdf)

In the United States there is a movement to limit or prohibit heading the ball by younger players. Several former U.S. Women’s National players are leading the movement. (http://blogs.edweek.org/edweek/schooled_in_sports/2014/07/us_womens_soccer_players_seek_to_limit_youth-soccer_headers.html ) The theory is that brain development is critically important to younger children and teenagers and allowing them to repeatedly traumatize themselves is unwise.  Dr. Robert Cantu, a founder of the Sports Legacy Institute stated “If we were to take a pillow and slam it as hard as we could against a child’s head, again and again, we would be charged with child abuse. But that’s exactly what it’s like when a player is hit in the head with a ball from pretty close.”  (http://www.nytimes.com/2014/06/25/sports/worldcup/us-womens-soccer-stars-take-lead-on-risks-of-heading.html )

A movement to address these issues is also underway in England as several members of parliament have called for a “Full Parliamentary Inquiry” into this matter which sounds like something very serious to my American ear. (http://www.chris-bryant.co.uk/archives/4698 )This report calls for limits on headers by children and some kind of action to avoid the same type of massive liability the NFL has recently accepted.  The NFL settlement is intended to last over 65 years and undoubtedly will cost the NFL more than $1 billion dollars by the time it is over. (http://www.nfl.com/news/story/0ap2000000363672/article/federal-judge-approves-nfl-concussion-settlement )  A detailed discussion of the NFL’s problems in this area and its long term denial that any problem even exists can be found in “League of Denial” by  Mark Fainaru-Wada and Steve Fainaru. (http://www.amazon.co.uk/League-Denial-Mark-Fainaru-Wada/dp/0770437540/ref=sr_1_1?s=books&ie=UTF8&qid=1407541895&sr=1-1&keywords=League+of+denial )  As a practical matter, it is likely that British Sport already faces some significant level of liability.

What does this have to do with Southampton FC? Possibly, a lot.  If the BPL is required to pay damages for past brain injuries, Southampton will probably have to pay its share.  More importantly, what is the club’s responsibility to the children in our world class youth program?  Should they be taught to head the ball at a young age risking some level of (possibly) permanent brain damage or should heading be prohibited until they are older--thereby limiting their development as players?  Moreover, since the dangers are now known, is Southampton FC courting liability simply by proceeding on a business as usual basis?

Finally, it may well be that taking appropriate and immediate preventative action will not actually hurt Southampton FC. Possibly, if Southampton players do not start heading the ball until age 16 they will, due to the lack of brain damage, be able to outsmart their opponents on a regular basis.

(I apologize for the weird formatting.  It doesn't look weird on my screen until after I publish it so I have no idea how to fix it.)