​We Spoke to a Neuropathologist About Head Injuries And Degenerative Brain Disease In Soccer

This article originally appeared on VICE Sports UK.

Earlier this month, the family of former England striker Jeff Astle spoke out about the link between head injuries in football and degenerative brain disease. Astle died in 2002, at only 59 years of age, after choking on a piece of food. He had been diagnosed with early onset Alzheimer's, and the coroner directly linked his condition to the manner of his death. An inquest found that repeatedly heading heavy leather footballs during his playing career had caused significant trauma to his brain; a verdict of death by industrial disease was recorded, strongly suggesting that his illness was connected with the beautiful game.

Astle made five appearance for his national team in the late sixties and early seventies, but he is perhaps better remembered for his decade-long stint at West Bromwich Albion, the club for which he played several hundred games and scored well over 100 goals. Much acclaimed for his heading ability, the sight of him towering above a hapless centre-back before nodding into the back of the net became iconic. His senior career spanned three decades, starting in 1959 and ending in 1977 with a brief loan spell at Hillingdon Borough.

By that time, the multiple minor traumas he received from headers had taken their toll.

The balls used when Astle was playing were much sturdier than today's equivalent. Made of leather and exceptionally heavy – especially when wet – it took considerable effort to head them with the required force. As perhaps the most renowned aerial threat in English football at the time, Astle had a reputation to live up to. Unknown to him, his headers were causing serious damage to his health.

Though Astle had been diagnosed with Alzheimer's prior to his death, a doctor who examined his preserved brain in 2014 said he actually had chronic traumatic encephalopathy (CTE). More commonly found in boxers and American football players, the condition is attributed to severe blows to the head and repeated concussions. In Jeff's particular case, there seems little doubt that heading footballs was directly linked to his death. That's certainly the view of his family, who formed the Jeff Astle Foundation in 2015 with the primary aim of raising awareness of brain injuries in all sports.

In light of the news that three members of England's 1966 World Cup-winning squad have been diagnosed with dementia, the FA announced earlier this month that it would be asking FIFA to investigate a possible link between degenerative brain disease and football. In response, Astle's daughter Dawn spoke about her family's battle to highlight the link between brain traumas from repeated headers and degenerative brain disease in later life. She discussed the FA's slow response to the issue and the need for more research, while claiming to know of up to 250 other former players that have suffered with similar illnesses.

Likewise, Dawn made it clear that she was worried for the current generation of professional footballers: "How it was described to me is the balls nowadays are much lighter but they travel faster, and sometimes players are much stronger and hit it harder," she told the BBC.

"It's down to the pure physics of something striking the head and the brain being rocked backwards and forwards in the skull. I hope to God that there isn't a link with the modern day ball but I would be very, very surprised if the safety implications aren't the same."

If the safety implications are the same, that should obviously be a significant cause for concern for fans, footballers and the FA alike. However, the scientific procedure involved in identifying a clear link between heading footballs and degenerative brain disease is extremely complex. While Jeff Astle's case is an exceptional one, it's often difficult to link head trauma in football – and sport in general, for that matter – to degenerative brain disease with a satisfactory degree of precision.

To get a medical perspective on the issue, I spoke to Steve Gentleman, Professor of Neuropathology in the Department of Medicine at Imperial College London. He made it clear to me that – although there could be a link between heading modern footballs and degenerative brain disease – it's difficult to be sure in the vast majority of cases. "You've got to be careful, because something like Alzheimer's disease, something put forward as a possible consequence of head injury, is in itself very common," he said.

"Relating it very specifically to head trauma in any individual is risky. You would have to be very confident in your understanding of their whole clinical history and everything else. It's hard to pin a degenerative brain condition down to a particular head injury.

"The current prevalence for Alzheimer's is something like one in 20 people aged 65. By the time you get to 85, it's one in five."

Considering that England's 1966 World Cup squad featured 22 players, the fact that three of them have been diagnosed with dementia isn't necessarily unusual relative to the general population. The rate of degenerative brain disease amongst them isn't anomalously high. Unlike Jeff Astle, it would be exceedingly difficult to link their illnesses directly to football, at least without more evidence. That's not to say that decades of heading old-style leather balls haven't played a part in their conditions, but rather that more research is needed before any firm conclusions can be drawn.

For that research to be effective, it needs to be long-term and in-depth. It's not enough to study former footballers as and when they become unwell; it's necessary to look at a large sample of players over a prolonged period. As Steve told me: "When someone has a head injury, they go to A&E. They're treated in hospital and they have a long stay in hospital.

"However, after they've been treated, they're ultimately released back into the community. If everything goes well, they're lost to follow up. But then, if you start seeing significant cognitive changes – things like memory problems, or issues with decision making 10 years down the line – there's not always that link back to trauma.

"There's not really enough longitudinal data. We need to follow individuals all the way through that history – that journey, if you like – from their playing career, through any injuries they may or may not have had and, subsequently, make an analysis of whether or not they have cognitive problems earlier than other people, whether they have different problems and so on.

"There are lots of unanswered questions. One can observe these problems in ex-players, but cause and effect are still not entirely clear."

Steve has done extensive work with the pathology of boxers. Considering the nature of their sport, it's far easier to identify repeated head trauma as a factor in any degenerative brain diseases they might suffer in later life. "The bottom line is that the pathology of the boxers is very, very similar to what is being reported in the US, in American football players, where we see chronic traumatic encephalopathy, or CTE," he told me.

"We are reconfirming this sport-associated degenerative change, which came to the fore in the US because the NFL commissioned studies. Scientists there have attempted to stage the progression of this change in the brain, and equate it to various clinical factors.

"The work with boxers is actually quite useful, because it helps to reinforce this [sport-associated degenerative change] as a pathological entity. This is something that is discrete, and is almost certainly due to repetitive head injury. It's not a big jump from boxers to other sports to realise that repetitive blows to the head are an issue."

Naturally, the link between head trauma and degenerative brain disease is nowhere near as obvious for modern footballers. While boxers take many heavy blows to the head, the heading of a football is less immediately destructive. Nonetheless, it's the repetitive nature of the activity in both training and matches that makes it so significant.

I asked Steve whether he thought the safety implications of heading the modern ball could be similar to those associated with heading the heavy, leather footballs of Jeff Astle's era. In essence, the answer is that we can't say for sure. Steve's personal view is that clashes of heads between players are more likely to be the main issue. However, he made it clear that more research needs to be done.

The Jeff Astle Foundation have come to the same conclusion. For widespread, longitudinal studies to be effective, researchers will require lasting investment from football's governing bodies. Whether or not those bodies can be convinced to commision a proper, in-depth investigation remains to be seen.

@W_F_Magee