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Dr Willie Stewart interview: This is a watershed moment - our management of head injuries must now improve

Jeremy Wilson
A recent study found that former professional footballers were 3.5 times more likely to die of dementia or neurological disease than the rest of the matched population

The need for further research into football’s dementia link is indisputable but, for Dr Willie Stewart, the lead investigator in the University of Glasgow’s groundbreaking new study, there is another pressing imperative. 

It is also immediate action. Nothing kneejerk. And not just confined to professional football, but tangible, meaningful and unified steps that will better protect people from head impacts across all levels of sport.

The findings from what was the largest ever study into the incidence of neurodegenerative disease in any sport were, after all, emphatic. Former professional footballers were 3.5 times more likely to die of dementia or neurological disease than the rest of the matched population. With a huge sample size of almost 8,000 ex-professional players, extensive peer-review before publication in the prestigious New England Journal of Medicine, and a methodology that involved verifying death certificates even with medical prescriptions, football’s governing bodies have had no choice but to face a difficult truth.

It is a truth, though, which also presents opportunity in an area of sports administration where progress has been frustratingly slow and inconsistent. “This is a moment to say our management of head injuries across all sports must improve from today,” says Stewart. “All sports should be doing the same thing. We should not have a position in rugby where a player is going off for 10 minutes to be assessed with really sophisticated sideline assessments and, in football, they are still managed on the park. You need to have a 10 minute assessment at least and, if that means a substitution goes on, then that’s fine. This is protecting a player’s brain. Sport has to stop talking about consensus in the management of concussion and deliver consensus.”

That coordination, says Stewart, should also extend to the ‘return to play’ protocols which can see rugby or football players back within days following concussion and a boxer face four weeks out of competition. “And all sports have to look at what happens outside of matchday,” he says. “Is there a way we can reduce the head impact and risk of head injury? Maybe reducing heading in training during the week. In rugby that could apply to contact training.”

Although it was a study which focused on professional footballers, a big hope is that greater concussion awareness will also spread to the grassroots. “Until somebody can prove this is no risk to the young, no risk to amateurs, no risk in rugby, we must assume the risk is there,” says Stewart. “When the parents are dropping their son or daughter off, and handing them over to the sports coach, they should ask, ‘What is your concussion management policy. Have you read the concussion guidance?’ If the coach looks a bit blank, put your arm around the kid and take them off to the next club down the road. There's a simple concussion message but so important: ‘If In Doubt, Sit Them Out'.” And heading among children? “Some of the data suggests young kids barely head the ball. I’m kind of the view that, if they are barely heading the ball at under-12s, why bother at all?”

Stewart has always been determined to outline the many wider health benefits of sport and the research also confirmed other important outcomes. The former footballers suffered less heart disease, they were less likely to develop lung cancer and lived, on average, for just over three years longer even despite the increased dementia prevalence. “Footballers in many ways have better outcomes than the rest of the population but this dementia is a problem - reduce unnecessary impact and then we would maybe have more benefit of participation,” he says.

The study is also not yet complete and, after only starting in March 2018, the next 18 months will be spent answering more nuanced but still vital questions. There will be further work to look at playing positions and also the age of dementia onset. The players were born between 1900 and 1976 and so trends through the playing eras are of major interest. For now, nothing can be assumed, particularly with regard to the old leather football. “There has been a suggestion this is all because they are old guys living in a bygone era,” says Stewart. “That’s simply not true. The study is involving some footballers who were playing in the last decade. It’s very much relevant to current and modern football.” The difficulty of distinguishing between heading and collisions as the primary risk to footballers is clearly hugely challenging but studies are being designed and progress should be made over the next decade. 

And crucially we now do have clear answers to some of the most fundamental questions. “We know football does lead to an increased risk of deaths from neurodegenerative disease,” says Stewart. “The really common thing that we see in all these inquiries [into sport and brain disease] is a link to head impact. I think there is more than enough to say that is the primary risk factor we have got to work with both for future research and to make immediate change in sport.”