Written evidence submitted by the Professional Footballers’ Association Call for evidence // Concussion in sport written evidence Introduction The Professional Footballers' Association is the union for all current and former football players and scholars across the four male professional English leagues and the Women's Super League. The aims of the PFA are to protect, improve and negotiate the conditions, rights and status of all professional players, both men and women, by collective bargaining agreements. The PFA is a key figure in all aspects of the professional game. The players' union believes in using the power of football to effect positive societal change and operates by the principle of caring for the interests of the game as a whole. The PFA and The PFA Charity have always been committed to a duty of care for all past, current and future members. The union has lobbied the football authorities to join with us on all aspects of health and safety in the game. Industrial Injuries Advisory Council In 2002, Jeff Astle, the former West Bromwich Albion striker, died at the early age of 59 after being diagnosed with dementia five years earlier. The consultant neuropathologist who examined his brain after his death stated, "I found that there was considerable evidence of trauma to the brain similar to that of a boxer. The main candidate for the trauma was heading a ball. It is the repeated trauma that appears to be the problem." The coroner also said, "His type of dementia was entirely consistent with heading a ball. The occupational exposure has made at least a significant contribution to the disease which caused death". Jeff Astle's brain was found to have Chronic Traumatic Encephalopathy (CTE), which is the term used to describe brain degeneration likely caused by repeated head traumas. This was the first time that it had been diagnosed in a former professional footballer and confirmed to have been linked to CTE. Since then, as far as we are aware, there have only been three other former footballers (Rod Taylor, Alan Jarvis and Nobby Stiles) who have died with dementia and then subsequently had their brain examined and found to have CTE. In 2003, following the coroner's verdict, the PFA made an initial application to the Industrial Injuries Advisory Council (IIAC) to request that dementia in former professional footballers be recognised as an industrial disease. In 2005, the application was rejected, with the IIAC publishing a report which concluded that there was "currently insufficient evidence to recommend prescription of dementia in boxers or footballers". In 2020, following the FIELD Study findings, the PFA has since supported a further application made by Nick Gates (son of professional footballer Bill Gates). We are still awaiting a decision from the IIAC regarding this. Research The PFA is now part of The Football Association's (The FA) Research Taskforce alongside other stakeholders in the game. Established in December 2019, the taskforce works to ensure a coordinated approach towards research into neurodegenerative disorders in former professional footballers. The panel includes medical experts in this field: Dr Charlotte Cowie, Professor Carol Brayne, Erica Pufall, Dr John MacLean, Dr Jonathan Schott, Margot Putukian, M.D., FACSM, FAMSSM, Peter Hamlyn, Richard Higgins, Dr Richard Sylvester, Professor Simon Kemp, Dr Carol Routledge and Dr Willie Stewart. Research: Neurological neuro-imaging and neuro-psychological effects of playing professional football In 2001, The FA and the PFA had jointly funded a 10-year study into the 'neurological neuro-imaging and neuro-psychological effects of playing professional football'. The study was conducted by academics Steven Kemp, Alistair Duff and Natalie Hampson. To our knowledge, this was the first longitudinal prospective study to follow-up a group of footballers and controls over time. Thirty-two young professional footballers were recruited, and 24 were identified at follow-up. Thirty-three controls were recruited, and 17 identified at follow-up. Medical examination, MRI (brain) imaging and detailed neuropsychological data were collected on the footballers at baseline and 5-year follow-up. Medical examination and detailed neuropsychological data were collected on the controls at baseline and 5-year follow-up. Unfortunately, due to several reasons outside of the PFA's control, this research programme was truncated and eventually reduced to a five-year project. The players participating in the study did not progress within the game as hoped, and in addition, over time, the researchers were unable to engage the original participants for follow-up examinations. The study was published in the Brain Injury Journal in 2016 - https://pubmed.ncbi.nlm.nih.gov/27184946. The results of the study were inconclusive and left many unanswered questions. FIELD Study In 2017, the PFA Charity – together with The FA - commissioned Dr Willie Stewart and the Glasgow Brain Injury Research Group to conduct research into 'Football’s InfluencE on Lifelong outcomes and Dementia risk’ (FIELD) at the University of Glasgow. The study took place in Scotland, after recent changes to their storage of digital health records made accurate data comparisons possible. The FIELD study is the first peer-reviewed research to determine that having played professional football correlated with an increased rate of dementia within its sample group. The results showed that the ex-footballers participating in the study had three and a half times the death rate due to neurodegenerative conditions than the control group. 7,676 former footballers were studied, each one grouped with three non-sporting members of the general public for comparison. The participants were matched by age, socioeconomic status and lifestyle to compare their risk factors and dementia status. Over 18 years - 1,180 of the 7,676 footballers included in the study died. Of which, 222 died from a neurodegenerative disease. Risk rates for the former footballers in the study varied across the subtypes of neurodegenerative conditions, with: A 5-fold increase in Alzheimer’s disease. Approximately a 4-fold increase in motor neurone disease. A 2-fold increase in Parkinson’s disease. FIELD Study Extension The PFA Charity, alongside The FA has committed funding for a further year (2021-2022) to Glasgow University to continue their research and to build on the initial results of ‘The FIELD Study’. The FOCUS Study The PFA, together with The FA, has co-funded ‘The FOCUS Study’ at Nottingham University to research brain function and joint health in former professional footballers. International Concussion and Head Injury Research Foundation The PFA has funded research by the International Concussion and Head Injury Research Foundation (ICHIRF) to examine ‘Head Injuries in Sport’ with jockeys and footballers. The Heading Study The PFA is currently working alongside The Drake Foundation who are funding ‘The Heading Study’ research programme by The London School of Hygiene and Tropical Medicine and Queen Mary University of London. The PFA has helped recruit 300 former players to help examine the link between heading the ball and/or concussions, and long-term cognitive function. New Call for Research into Neurodegenerative Disorders This year, the PFA and The FA have invited applications for further independent research into neurodegenerative disorders in former professional footballers. Following the insight provided by the FIELD study, the PFA and The FA will now jointly fund new independent, evidence-based research into the increased risk of death from neurodegenerative disorders in former professional footballers, focusing primarily on what causes the increased risk. It is The FA’s independently-chaired Research Taskforce, that plays the crucial role in this process, and this group of industry and scientific experts shape the policy, direction and decision-making when identifying specific areas for research. The expert panel have set the question on the new call for research: “What is the cause of the observed increased risk of death from neurodegenerative disorders in former professional footballers found in the FIELD study?” Research applications are encouraged to address secondary questions such as the risk to current players, risks at different levels of the game, the nature of any risk in childhood, the risk in other sports and the risk in women’s as well as men’s football. The FA’s Research Taskforce will establish the potential viability and validity of any application. Once selected, The FA and PFA will jointly fund the new research. Protections for Current Players Regulatory changes In 2006, following the injury sustained by Petr Cech in the Chelsea v Reading game, the PFA lobbied the Premier League (PL), English Football League (EFL) and The FA with regard to reviewing the treatment of head injuries and other significant injuries in competition and in training. As a consequence of this, a change was made to the regulations in both leagues, which required clubs to share medical information on the facilities available at grounds and also to ensure that all medical staff had the necessary sports medical qualifications. A football-specific course was developed - Advanced Trauma Medical Management in Football (ATMMIF) which ensures quality assessment in the areas of resuscitation and emergency aid. All medical staff at clubs who are treating players must have completed the course to practice in professional football. In 2013, following an injury to Hugo Lloris in the Everton v Tottenham game, the PFA assisted with the development of an educational campaign aimed at all participants within the game and a review of the assessment and treatment of head injuries and concussions. This resulted in the introduction of new guidelines and rules for the 2014/15 season for the management of concussion and head injuries in football. The guidelines set out the important procedures and processes that follow any suspected head injury and how players should be re- introduced to competitive football over time through the new ‘return to play’ rules.