Football, Heading and Dementia

3:  International Footballers Who Have Suffered From Dementia

The former German international footballer Gerd Müller is suffering from Alzheimer's disease.   The Hungarian footballer, Ferenc Puskás, also died after suffering from Alzheimer's.  The death of Hilderaldo Bellini, a former Brazilian defender, is significant because he was posthumously diagnosed with CTE.  This is similar to the case of Jeff Astle whose brain was re-examined and found to show signs of CTE.

4:  International Footballers Who Have Suffered From Motor Neurone Disease

There have been cases of MND, in Italy, with the deaths of Stefano Borgonovo, Gianluca Signorini and Adriano Lombardi.

PART 2:  A Discussion on Former Soccer Players with Cognitive Decline  

 1:  The Debate on Footballers with Dementia

The list, in part 1, provides an incomplete record of former UK footballers who have suffered from dementia.  The record is not comprehensive as it does not cover less well-known professional players or amateur footballers.  The list is based only on publicly available sources which are accessible on the internet.  The record is similar to a list of American footballers who have experienced CTE (chronic traumatic encephalopathy). The register covers a range of different types of dementia including Alzheimer's disease, CTE, vascular dementia, Lewy body and pick disease.  The list covers many famous players who played for England, Scotland, Wales or Northern Ireland.  These footballers include Tottenham's Dave Mackay, Peter Baker and Ron Henry.  Other prominent players who were listed are Ron Yeats and Joe Mercer.

It was difficult to compile the record as it is unclear which players should be included.  Jimmy McIlroy was listed despite the Times' obituary, which suggested that heading was not relevant to his health.  Jack Charlton was incorporated because it was revealed that he suffers from severe memory loss.  Frank Worthington has also been included, based on memory loss, although his diagnosis was denied.  Mike Sutton's case has recently been discussed and so he was put on the list.  Chris Nicholl spoke about the cognitive challenges he faces; but there was not a formal diagnosis in 2017, so he is not on the register.  However, the high number of games he played is interesting as he had 698 senior games including international matches for Northern Ireland.  His central playing position is also relevant, as defenders had to block many shots with headers and so his risk is likely to be greater than a winger on the side of the pitch. 

Some professional players would have played less than 50 games.  These players are like occasional amateur footballers or even non-footballers.  Consequently, the dementia researcher is likely to be less interested in these players.   Longer soccer careers are of greater significance because footballers who competed for an extended time may have an increased risk of dementia.  It is more useful to look at the number of games played over a career rather than the length of the profession as it would be possible to play relatively few games despite a long career.  The players who completed more than 500 games deserve the greatest scrutiny.  In theory, these players have the greatest level of risk because they have played the most games.  It is interesting that dementia sufferers Jack Charlton, Ernie Moss, Martin Peters and Frank Worthington are towards the top of the list, for the number of games played.  Goalkeepers could be excluded from a dementia analysis because they do not head the ball.  Also, players who died young, such as Bobby Moore at 51, could be omitted as it is unclear whether he would have suffered from dementia had he lived longer.

2:  Research on the Link Between Football (Heading) and Dementia: A Cross-Table

3:  More Detailed Research on the Link Between Football (heading) and Dementia 

More sophisticated statistical research is needed.  It is necessary to categorise a footballer by (1) the position played or (2) the number of games played.  Therefore, it could be possible to link the footballer to dementia as follows:

(1)  The possible link between position played and dementia

(2)  The possible link between the number of games played and dementia

It would also be possible to separate the 'generic label' of dementia into different categories of the disease.  This could examine: 

(1a) The possible link between position played and Alzheimer's disease.

(1b) The possible link between position played and Pick's disease (a type of dementia).

4:  Method for Measuring the Length of the Player's Career and The Age of the Footballer when they Died

The length of the footballer's career was found by taking the last year of the career (where games were played) and then subtracting the first year of the career.  For example, 1966-1950=16.  However, information can be missing, especially, with games played in the non-league after the end of the player's formal career. The age of the footballer when they died after suffering from dementia is commonly available.  The age of death is of interest to a statistician trying to explore the link between football and dementia.  This is because an earlier death could indicate a more serious form of dementia.  

5:  A Model of Dementia in Retired Footballers

There could be a four-stage process of dementia in former footballers.  First, there is stage 1, where the player starts suffering some memory loss years after retirement.  Second, there is stage 2, where the player is formally diagnosed with dementia.  Third, the needs of the footballer become so great that they require care in a nursing home.  Fourth, the player dies of dementia.  This process could take 30 years to be completed; see a hypothetical chain of events below:

Stage 1 (memory loss, at age 60) 

Stage 2 (confirmation of dementia, at age 70)

Stage 3 (entry to care home, at age 80) 

Stage 4 (death, at age 90)

Evidence, from the wives of former footballers, could explain whether this is a pattern which emerges.  An article on the former footballer Alf Wood from 2014 suggests that his mental health was failing in 2004, (stage 1), when he started to struggle with reading. He was diagnosed with dementia, in 2007, (stage 2).  His condition saw him move permanently into a care home, in 2013, (stage 3). There is a more traditional explanation of brain injury in sports people available. 

6:  Summary

Over 100 footballers have developed dementia after playing the sport.  About half of the dementia cases were labelled as Alzheimer's disease and a significant number of former players died of Alzheimer's in their 80's.  In the general population, 17 per cent of people over the age of 80 have dementia. There were enough examples of dementia, in former footballers, to justify a full scale study at Glasgow University in 2017.

PART 3:  State Intervention:  to Reduce Brain Damage from Football

Summary Video 

1:  Previous Cases of Dementia in Former Footballers

This section outlines some previous examples of dementia in former players.  Members of the Aston Villa, 1957 FA Cup, winning side may have died as a result of brain injuries from heading footballs.  Spurs players, from 1961 have suffered from dementia and Danny Blanchflower, who captained Tottenham, that year, died after suffering from Alzheimer’s disease in 1993 (aged 67).  Former footballer, Ian St John, has highlighted neurological problems among former 1964 Liverpool players such as Tommy Smith and Geoff Strong.  Also, members of the 1966,  England World Cup Winning Team have dementia.  

A coroner ruled Jeff Astle, the former England footballer, renowned for his heading ability, died from dementia caused by repeatedly heading the ball.  Astle died of Chronic Traumatic Encephalopathy (CTE).  This is a disease caused by impacts to the head which produced symptoms, like dementia, including memory loss.  It is a form of dementia that occurs when the frontal lobes of the brain begin to shrink and could be responsible for 10%-15% of dementia cases.  Other significant cases of dementia, in former footballers, include John McNamee, the former Newcastle United central defender and Billy McNeil, the former Celtic central defender.  There is also the case of the former Cambridge defender Chris Turner who died of dementia which was attributed to heading footballs.

Brandi Chastain, the former women’s American soccer player is highly aware of the possible links between playing football and dementia.  She has agreed to donate her brain to medical science when she dies.  In the UK, former Blackburn strikers Alan Shearer and Chris Sutton are leading calls for more research into the possible link between heading footballs and dementia.  Further research is needed to build upon the examples of dementia which have been identified.

2:  A Model to Show Greater Public Awareness of Dementia and Sport

In 2014, the former England test cricketer, Ed Smith, wrote an article on the possible links between American football and brain damage.  From this article, a model of ‘awareness of sporting risk’ and dementia can be developed.  The model argues that, first, there was an awareness of the links between boxing and dementia; going back to 1928.  More recently, there has been an awareness that participation in American football, rugby and soccer can lead to dementia.  With the death of the batsman Philip Hughes concern over risk could reach cricket.  A solution might be that any ball bowled over shoulder height is counted as a wide with one run added to the batting team’s run total.  The batsman cannot be out, from such a delivery, except by means of a run-out.

3:  The Number of Times a Player Heads a Football During a Career

If a player makes 10 headers, per game, with 50 games per season, including competitive pre-season friendlies, then that is 500 headers per season.  If there is a 20 year long career (500*20) then that is 10,000 career headers in total.  Another estimation suggests that football players play 300 games and head the ball more than 2000 times during their careers.  However, these figures do not measure the number of headers completed in practice.  Alan Shearer estimated that he headed a football, in practice, 150 times a day.  This is relevant because sub-concussive events, where a player heads a ball but there is not concussion or pain, can lead to neuro-degeneration.

4:  Issues for Football to Address 

Type of Ball (The Difference Between the Older and Newer Ball)

The older match ball may have been of a higher standard than the much-kicked training ball.  Therefore, the older training ball could have presented a greater risk, to the footballer, than a newer training ball.  Also, the older footballs may have become more dangerous as they became heavier with the rain water.  However, newer footballs are more aerodynamic and modern players can kick the ball harder due to greater athleticism.  Therefore, the newer football can travel faster and can still be dangerous due to the greater force of impact.  The newer ball may not be safer than earlier versions of the ball.  This is because the relevant factor which determines brain injury is the amount of energy imparted on the head by the ball; rather than the weight of the ball. It should also be acknowledged that heading a football can give players worse brain injuries than unintentional head collisions.

Playing Position (Greater Risk for Central Defenders and Centre Forwards)

The football industry needs to consider whether some footballers are at greater risk of dementia.  The central positions, such as central defenders and centre forwards, could be at greater risk of dementia, due to the need to head the ball near the goal.  Such players may require greater protection from the 'rules of the game'.

Possible Rule Changes (A Ball-Height Rule and New Dimensions for the Goal)

The most dangerous form of header can be from a long clearance from a goalkeeper.  Presumably because of the length and speed of the kick.  There could be a modification to the existing game where it is not permissible to head the ball from a goal kick.  However, this would be an unnecessary complication.  To fully reduce the dementia risk from heading, then a 'kick-ball' game is a viable option.  It is simpler and safer to have a game where the football is kept at ground level; below 1.5 metres in height.  There is an opportunity to have a 5 a side type of game with eleven players on an 11 a side sized pitch.  A free kick could be awarded, to the opposing team, if the football is clearly kicked above shoulder height.  Yellow and red cards could be used to deter heading.  Also, the goal posts could be changed to accommodate a game without heading; a new goal dimension of 1.5 metres, for the height, and 12 metres for the width could be appropriate.  A move towards a 'kick ball' removing a feature of the game that should not have been present from the 1870's onwards. The sport does not have to be too affected as playing the ball along the ground is a feature of Manchester City's tactics.  This does not affect their play as they are top of the English Premiership in 2017. 

5:  Issues for the Government to Address

The case of mad cow disease, in the United Kingdom, provides an example of an industry which failed to regulate itself. Earlier intervention was needed to address concerns over animal welfare and food safety.  There is a similar problem with football.  The large number of cases of dementia in former footballers suggests that the soccer industry has not maintained safety among its players.  This (potential) failure to provide a safe sport, is a public health issue and the basis for government intervention.  Only in 2017 did the football industry properly consider the risk to the brain from heading the ball.  

6:  The Aim of Research

Government research on dementia is needed to understand the extent to which dementia is caused by sports; and how far dementia can be attributed to other causes.  The government needs to try and separate (1) the extent of dementia caused by brain injury from (2) the dementia caused by other factors such as diet and lifestyle (vascular dementia).  Prion disease (CJD), related to mad cow disease, could also be examined as a cause of dementia in the population.  A Royal Commission examining these wide-ranging concerns is a relevant method of investigation.  A fully funded research programme is needed; to bring together evidence from around the world into the effects of impacts on the brain.  

PART 4:  The Need to Reduce Heading as part of Football (Soccer)

Summary Video

1:  American Football

The data on head injuries from American football may have implications for the regulation of British football.  Research has shown that up to 71% of players who have sustained concussions will develop CTE (Chronic Traumatic Encephalopathy). Concussions can be defined as multiple mild traumatic brain injuries (mTBIs).  Another study examined the brains of 111 former American football players and found CTE in 110 of them.  A more general examination of the brains of former gridiron players found that nearly 90 percent showed signs of the disease.  It has been argued that ex-NFL American football players are more likely to develop neurodegenerative diseases compared to non-footballers.  Due to the effects of concussion in American football, then there is a need to examine the safety of English football or soccer.  Evidence from American football has been used to argue that heading in soccer should be discouraged. 

2:  English Football

The football industry should be concerned with brain injury possibly resulting from the game.  There are teams, of former footballers, where at least 3 out of the 11 players have dementia (27 percent); this compares with 1 in every 14 (7 percent) of the general population aged 65 years and over.  Footballers need to be aware that the brain does not have the complete ability to mend itself; and that short term brain function can be affected by heading a football whether this is in a competitive game or in a practice session.  

3:  CTE and Motor Neurone Disease (MND)

The scientist, Bennet Omalu, argues that the football industry needs to be concerned with other possible types of brain injury apart from CTE.  There is a need to examine motor neurone disease too and whether this is partly caused by heading a football or head to head soccer related collisions.  A Turin University study found that the risk of motor neurone disease was six times higher among former footballers compared with normal rates of the disease.  The possible link between football and motor neurone disease should have been thoroughly explored in 2003 after the deaths of former footballers from motor neurone disease.  These include the former Sunderland players Rob Hindmarch and Mel Holden and the Middlesborough player Willie Madren.  The former Hartlepool footballer Len Johnrose, and the ex-Liverpool player Stephen Darby, were diagnosed with motor neurone disease.  Research needs to be undertaken to find out whether this disease was caused by playing football.  A correlation does not mean that there is causality but these cases merit further investigation; in the context of the Turin research. 

4:  Lessons Which Should Have Been Learnt

The possible links between heading and dementia could have been researched, thoroughly, after the death of Danny Blanchflower from Alzheimer's disease in 1993.  There have been numerous deaths from dementia many of which could be attributed to playing football and these deaths were overlooked in the past.  The soccer industry has known about the deaths of Danny Blanchflower from Alzheimer's in 1993, and Rob Hindmarch, from motor neurone disease in 2002; and this is before the clearest link between football and dementia with the death of Jeff Astle; again in 2002.  Extensive neurological research should already have been undertaken into football and brain injury.

5:  Newer Footballs: The Challenge of 'Brain Injury' Remains  

The former Ireland striker Kevin Doyle retired from football aged 34.  He wanted to avoid any long term health problems  associated with heading as he has suffered from concussions as part of his career.  This case needs further examination because it could be the start of a trend of footballers needing to retire early; despite the newer and possibly lighter footballs which have been used in the 21st century. The number of 'aerial collisions', where footballers compete for the ball, could help explain the number of concussions and headaches in footballers.  These clashes occur regardless of the type of ball used.  A restriction on heading should reduce head on head player contact and  head to elbow contact.  This is because footballers are not having to compete for the ball with their heads.  A revised form of game should reduce the number of head collisions.  The football industry needs to be concerned about clashes of heads, or where a footballer elbows an opponent's head, given the possible increased risk of dementia in later life.

6:  The Link Between Football and Brain Injury

Scientists have yet to demonstrate definitive links between impacts to the brain and the development of dementia. However, in the most likely explanation for dementia, in former footballers, is playing the sport.  Evidence suggests that teams from the 1950s and 1960s have five or six players who have developed dementia.

7:  Conclusion:  Voluntary or Mandatory Regulation

If the risk of harm from heading and 'aerial collisions' is accepted, then a decision is needed over the adoption of voluntary or state intervention.  The football industry could choose to introduce a 'kick ball' game where heading the football is penalised.  However, if the soccer industry continued with heading, as part of the game, then the government should announce additional taxation on the sport to encourage a rule change towards a non-heading game.  The government should intervene to try and reduce the level of brain injury in society.  Football could find itself in a similar situation to the 'mad cow disease' crisis of 1996; where the health minister announced a possible link between BSE and CJD.  The UK government was obliged to introduce further measures to reduce the incidence of 'mad cow disease'.  

PART 5:  The Cost of Brain Injury to Health Services

Summary Video 

1:  Football, Heading and the Implications for Society

The costs to the National Health Service (NHS) are outside of the decisions made in the football industry regarding what is an acceptable level of 'footballer  safety'.  The football industry takes action to meet its own needs. It is now common practice, for a footballer with a head injury, after competing for a ball in 'the air', to be substituted.  However, this may not prevent long-term brain injury; particularly as a player could be passed fit to play again soon after the game.  There is still potentially a long-term impact on the health service; the footballer and his family.  This is a cost which can be overlooked by the industry.  A comparison can be made with smoking.  Smoking imposes costs on the NHS; as the NHS is expected to pay for the treatment costs of smoking related illnesses.  In comparison, the NHS will be expected to pay for the treatment and care costs of a retired footballer, if they develop dementia from playing football.

2:  A Solution to the Social Cost of Head Injury from Football

The welfare of the footballer must take precedence over the needs of all the spectators who want to watch football.  The need to protect the brain of the sportsperson must take precedence over the sport as a spectacle.  Players have the right to have their brains protected from damage.  The sport could significantly reduce the number of head injuries by reverting to the original Football Association rules of 1863 where the game was played without any heading of the football.  The heading of the ball only emerged 12 years later.  A nominal tax could be levied on football to encourage the sport to revert to being played using the feet only.  This would be like taxation on cigarettes to reduce the incidence of smoking.  Such a tax could be removed if the game returned to the original rules.  However, if the industry were to ignore future cases of dementia among former footballers, then the level of taxation could be significantly increased.  The justification of this measure is that football needs to be treated in the same way as other sectors of the economy.  Industries which damage wider society need to have their activities corrected.  If a factory polluted a river and the water became polluted then government intervention would be expected.  Many former professional footballers have died prematurely from dementia and this could be attributed to heading a football.  The concern is not just over premature death but also the loss of quality of living in the later years of a player's life. The effects of playing football could be felt for decades after the end of a playing career.  The football field is the place of work for the footballer and the industry has a duty of care to protect players from unnecessary injury. It is unacceptable for a footballer to lose consciousness due to a 'clash of heads' when there are safer rules available which should avoid this outcome.  It is unacceptable for traumatic brain injuries to be considered as an occupational hazard.

3:  A Discussion on the Health Implications of Playing Football

Further research is needed into heading a football and the potential for long-term brain damage.  However, government action should be taken regardless of the need for additional investigation. The main reason for this is to avoid a clash of heads when footballers compete for the ball, in the air, particularly in and around the penalty box.  It should be possible to reduce the number of head injuries substantially although foot, ankle and leg injuries will remain.  The cardio-vascular benefit of playing football could lead to an individual living longer; but this benefit could be more than offset by the (possible) brain damage caused by heading a football.  A five-a-side or kick-ball game will have cardio-vascular benefits without the (possible) cognitive decline caused by heading.  The exercise benefits of football can still be achieved, with a 5-a side game, where the ball is played on the ground. 

PART 6:  The Need for a Preventative Sport and Dementia Strategy

1:  The Need for a Preventative Sport and Dementia Strategy 

In the 19th century a doctor, in London, made a hypothesis and was able to trace an outbreak of cholera back to a contaminated water pump.  The closure of this water pump led to the elimination of the source of the disease. The football industry could learn from this experience.  Action could be taken to reduce the level of dementia in former footballers.  A kick ball game could be introduced without any heading.  This measure could be introduced without a complete understanding of the relationship between playing football and  then suffering from dementia.  Preventative action can be taken without a full understanding of the scale of the health problem as was the case with the reduction in cholera.  Scientific research would help in understanding the possible link between football and dementia.  The government needs to fund studies to this effect.  There is already a parliamentary report  which examined sport and brain injury. A strategy now needs to be formulated to reduce the impact of sport on the brain.  A preventative approach is needed, so that action can be taken before the incidence of brain damage increases.  Such a pre-emptive strategy would be similar to policy advice to reduce flooding and anti bacterial resistance. 

2:  A Preventative Decision-Making Approach 

A preventative approach would aim to reduce the incidence of dementia, and the costs of dementia, among former sports people.  A government study would also examine what state interventions are needed to reduce the number of brain injuries.  This would entail an evaluation of different policy options such as outright prohibition, taxation or a softer marketing approach; where the risk of heading is communicated to a footballer.  An outright ban on heading footballs would be expensive to enforce.  Evidence from  fox hunting also highlights the complexity of trying to enforce prohibitions.  Additional taxation is an appropriate policy tool; as it has been applied to smoking cigarettes and sugar in soft drinks.  The communication approach is less appropriate because it allows the current situation to continue and the conflict of interest, in football, to go unchallenged.

PART 7:  The Need to Resolve Conflicts of Interest

Summary Video 

1:  The Lesson from the Alan Shearer Documentary

It is unwise to jump up and control a ball, travelling at a high speed, with your head.  This is because the human brain is like a balloon inside your skull, so when you head the ball you can suffer measurable brain damage.  The scientist, Michael Grey states that "football is the only sport where the head is used as an instrument to hit the ball".  This is a crucial point made in the Alan Shearer documentary (see 11:50).  The player's head is being used like a cricket bat or tennis racket to control or direct the ball.  This is relevant given that the human brain is a fragile structure, with the consistency of jelly.  Arguably, decisions, regarding the rules of football, should be evidence based.  However, further proof is not required, to stop the head from being used as a sporting instrument.  The government should intervene to discourage the skull from being used as a tool to move a football.  The consequences of dementia can be so severe that additional taxation should be applied to the football industry.

2:  Conflicts of Interest: The Justification for State Intervention in Football

The possible link between football (heading) and dementia was discussed in 1995.  The former Ireland striker Tony Cascarino stated that: "even if there was proof (of a link) I doubt if it would make much difference. It's a risk people are prepared to take.  They think of their careers and carry on taking the money".  This statement provides a justification for government intervention.   If the footballer is unwilling to protect themselves, then the state needs to interfere to protect the player, the player's family and the wider society.  This involvement needs to happen even though the link between heading a football and dementia is not fully understood.  A representative for the industry believed that “heading is a tremendous part of the game" and should not be taken out of soccer.  However, the football association is researching the potential for brain injury from playing the sport and may ask for a disclaimer form.  In which case, footballers will be obliged to accept the risk of future brain injury.  This approach shows a willingness to tolerate dementia in retired players.  The football industry is behaving like a factory which pollutes a river (see section 5.2).  The costs of dementia are being passed onto society; namely the national health service, the footballer and the footballer's family (see section 5.1).  The soccer player's family have frequently borne the intangible caring costs of looking after a retired player with dementia.  

However, the welfare of retired soccer players should take priority over the game of football.  As Alan Shearer states, former footballers still have lives to lead.  Significant measures are needed to reduce heading and lessen the risk of dementia in former players.  Measures which are limited in scope, such as banning heading for children under the age of 12, do not protect professionals.

3:  Bias and Optimism in the Football Industry

Another concern is that prioritising a football career may lead to a bias in favour of optimism.  A player suggested that "these days the balls are a lot softer and a lot better".  This statement may be true but scientific concerns remain.  The brain injury risk may be no lower now than in the past.  The newer balls still transfer a significant amount of energy to the head and to the brain. The footballer's optimism provides another reason for government intervention.  The state needs to make sure that a footballer is not damaging their brain and under-estimating the risk to themselves.

4:  Conclusion

The families, of the retired footballers with dementia, lack funding compared to the football industry.  These families have also found it difficult to link playing football with dementia, so their concerns have generally not been raised by politicians.  Therefore, in comparison to the football industry, the families are politically weak.  This can help explain why, in 2017, no rule changes have been introduced into the game of football.

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