Written evidence submitted by the Professional Players Federation
DCMS Select Committee
Concussion in Sport Inquiry
The Professional Players Federation (PPF) was founded in 1991. We represent the collective interests of twelve player associations based in the United Kingdom covering a range of sports. Through the membership we represent around 17,500 professional sportsmen and women. This submission gives a collective response and we are pleased to support the separate submissions from the Professional Footballers Association (PFA) and the Rugby Players Association (RPA).
Brain injury is an important issue for the Player Associations in football, cricket, rugby union, jockeys and netball.
Professional sport is a highly trade unionised industry with membership rates in excess of 90% in our major sports. The sports trade unions are actively involved in negotiations around working conditions and health and safety.
There is still a range of different medical opinions on many of the issues around concussion, sub concussive blows and long and short-term brain health. Whilst it is important to err on the side of safety, it is also important to consider the opinions of a range of different medical experts as research develops.
The Lancet Commission in 2020 has recognised that there are 12 modifiable risk factors for developing dementia which included traumatic brain injury. It is unclear how genetics affect the development of dementia with regards to brain injuries in sport.
Scope of the Inquiry
The term concussion can be divisive and it may be better to refer to brain injuries when speaking in general terms and traumatic brain injuries rather than concussion where applicable.
It is essential that women’s sport is given adequate consideration due to evidence of different effects of brain injury on women.
Brain injury in sport is an international matter and we would encourage the Committee to consider the leadership of international sports federations in this area.
In October 2015, the PPF published its “Pan Sport Minimum Standards for Concussion Management” developed in cooperation with Dr Willie Stewart.
In January 2017, Dr Michael Turner of the International Concussion and Head Injury Research Centre presented his research initiative to the PPF members. The PPF and its members agreed to actively support this research through the recruitment of former players from a range of sports for its database.
We continue to help share information across different sports on brain injury and dementia.
Industrial Injuries Advisory Council
In May 2003, the PFA wrote to the Industrial Injuries Advisory Council (IIAC) to request that dementia in footballers be considered a recognised industrial injury.
In November 2005, the IIAC published a report which concluded that there was “currently insufficient evidence to recommend prescription of dementia in boxers or footballers”. The report also found no research on dementia following head injury in jockeys.
We believe the bar for evidence is being set too high by the IIAC. It is incredible that it could find insufficient evidence for dementia in boxers to be classified as an industrial injury; especially given that dementia pugilistica was first identified in the 1920s.
The PFA wrote to the IIAC once again in March 2020 to endorse the request to prescribe neurodegenerative disease as an industrial disease for ex-footballers. We are unclear whether the IIAC is currently considering this request.
We note that the IIAC requires that any research to support the prescription of industrial diseases is independent. If funding of research by sports means that it would not be independent then this puts the sports involved in an awkward position.
There are no easy answers to the complex issue of brain damage and dementia in professional sport. We note that repeated sub-concussive blows are important to consider as well as concussive and traumatic brain injuries.
The Player Associations have supported a number of research projects both through direct financial support and helping with the recruitment of players and former players.
The PFA and its charity have supported the following research projects:
Both the PFA and the League Managers Association (LMA) are supporting the research studies announced in March 2021 into heading using smart mouthguards to inform heading in training guidelines. These studies are being undertaken by the Premier League on behalf of the Professional Football Negotiating and Consultative Committee.
The LMA is providing support for and promoting a number of research projects, and continues to liaise with the UK’s major dementia charities on all requests for research support. It has pledged its support to the work of the SCORES project, which is being run by neuroscientist Dr Michael Grey and Professor Michael Hornberger.
The LMA has recently endorsed the Sporting Mindset campaign by a group of NHS medical professionals which aims to raise awareness of the link between concussion and dementia.
The RPA has supported the following research projects:
Since 2017, the Professional Jockeys Association has been supporting the International Concussion and Head Injury Research Foundation.
It is interesting to reflect upon observations from the Professional Jockeys Association that there does not appear to be significantly elevated levels of dementia in former jump jockeys. Given that jump jockeys can expect to fall off a horse approximately once in every 20 races this looks to be worthy of further research. It is possible that dementia cases in retired jockeys are not being recorded or that some other factors are at play which are specific to racing.
PFA Scotland will be funding a research programme called PREVENT FC over the next two years. This sits alongside the FIELD research programme and will give a more detailed analysis of the brain and wider health in former professional footballers aged between 40 and 59 compared to existing research datasets on 700 general population controls.
The Player Associations are working to help educate current and former players about the risks of concussion and brain injury. This is generally being done in conjunction with other stakeholders in the sport both nationally and internationally.
In 2013, following an injury to one of its members, 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.
PFA Scotland has delivered an education programme directly to its members by the use of video, dressing room visits, magazine articles, awareness posters and direct social media messaging. Additionally, PFA Scotland has supported a Concussion Guidance programme produced by the Hampden Sports Clinic for grassroots football.
This year the LMA held a Brain Fitness webinar hosted by leading neuroscientists for its members.
Since 2014, the RPA, RFU and Premiership Rugby, have delivered mandatory annual concussion education (via online or face to face delivery) to all professional players, coaches and referees in the Premiership, Championship and for England representative teams.
In February 2021, the RPA held its first Brain Health Webinar for retired RPA members, providing information and expert opinion on mid-life brain health and neurodegenerative disease, featuring Dr Willie Stewart, Dr Richard Sylvester, Professor Craig Ritchie and Dr Fiona Wilson.
Given that the Lancet Commission has recognised twelve modifiable risks for dementia, the scope for providing education for former players on how to minimise the risks of developing dementia is something that the PPF has shared amongst its membership.
The Lancet’s 12 Modifiable Risks
The 2020 Lancet Commission report into Dementia prevention, intervention and care identified 12 modifiable risks of dementia.
For the first time, these included head injury and it is an important step that the scientific community is now recognising this cause of dementia. We trust that the IIAC is now prepared to recognise dementia in professional sport as an industrial injury.
Amongst the other risk factors identified are excessive alcohol consumption, depression and education. It is important for the committee to note that the sports trade unions spend millions of pounds each year on these areas as part of their holistic support for their members. Career transition and education for life after sport is a major investment for all the Player Associations. This is helpful in itself and also helps to reduce the incidence of depression when sporting careers finish.
On mental health, the Player Associations spend about £1 million each year to support the mental health of athletes with depression and anxiety featuring heavily in the issues that players are supported with.
Finally the Player Associations would like to record their support for the Sporting Chance clinic set up by Tony Adams and funded by the PFA. Many associations work with the clinic to support players who may have problems with alcohol and other addictions.
The recognised trade unions for professional sportsmen and women have an important role when it comes to all aspects of working conditions. This includes changes to working practices and the rules of the sports to make it safer for professional players.
In cricket in 2015, there was a joint review by the ECB and the PCA of existing safety guidance to reduce the risk of head and facial injuries within the game. Key measures that arose from this review included:
In 2006 in football, following the injury sustained by one of its members, the PFA contacted the EPL, EFL and FA with regard to reviewing the treatment of head injuries and other significant injuries in competition and in training. Through consultation with stakeholders this led to a change to the regulations in both leagues.
In 2015, the FA Expert Panel on Concussion and Head Injuries was formed with the PFA as an observer.
More recently the PFA are calling for changes to working practices for footballers such as
The RPA works collaboratively with the RFU and Premiership Rugby to deliver a co-ordinated approach to concussion risk management in English professional rugby union, which has seen many positive developments in recent years, particularly in relation to concussion management, prevention and education. The RPA has also successfully lobbied for:
The RPA also works with International Rugby Players, to positively influence matters at an international level with World Rugby e.g. providing RPA member feedback and input for World Rugby’s High Tackle Sanction Framework and, more recently, the Head Contact Process.
The RPA believes that action must be taken to reduce the level of exposure to both concussive and sub-concussive head impacts by removing all unnecessary head impacts and reducing exposure to head impacts of any kind. In particular, the RPA believes that action should be taken to introduce limits on contact training in the professional game.
The Welsh Rugby Players Association is part of the WRU’s medical committee to challenge and check work on player safety and brain health.
A number of Player Associations have benevolent funds that provide thousands of pounds to help former players that need help. This funding tends to be confidential and is therefore probably not given the recognition it deserves.
In 2020, the Player Association charities provided significant funding for a range of issues including education, hardship support, mental health and research which were related to a range of issues including dementia.
The PFA and Sporting Memories, jointly produced a practical guide to living with dementia for people who have received a diagnosis and for their relatives/carers. More recently, the PFA have partnered with Sporting Memories to pilot events for former players with dementia and their carers to socialise with other former players.
The PFA provides a range of support for former players that are living with dementia. This includes:
Since 2017, the RPA has had a pathway (funded by its charity, Restart) that supports former players with concerns regarding their brain health, by referral to its confidential counselling service (delivered by its mental health treatment provider, Cognacity) and neurologist expertise at the Institute of Sport Exercise and Health.
The LMA Wellness programme, guided by its Medical Advisory Committee, provides all members and their families with access to specialist healthcare consultants, LMA-funded physical and brain health assessments, support to members and their families diagnosed with dementia, and independent welfare rights advice.
Impact of Covid
The sports trade unions’ charities and benevolent funds provide significant hardship funding to former players in need of help. Unfortunately for many sports – especially rugby and cricket – these charities have been hard hit by the loss of fundraising opportunities due to the pandemic and the loss of crowds.
Despite a number of requests to DCMS, there has been no pandemic funding made available to the Player Association benevolent charities which risks undermining the excellent work that these charities are doing to support current and former players in hardship.
The Player Associations have a number of partnerships with brain health charities which include:
The RPA has a partnership with Sporting Memories and is also exploring partnerships with other brain health charities.
The PCA has partnerships with the following health charities: Sporting Chance, Sporting Memories and Sport United against Dementia.
The PFA is working with the Jeff Astle Foundation and Sporting Memories on issues around dementia. In addition, the PFA has funded the Sporting Chance Clinic since it was set up in 2000.
The LMA has a number of close links with national charities specialising in dementia care. Each organisation provides priority assistance, depending on the specific area of need, for example access to Alzheimer’s Society’s dementia advisers and Dementia UK’s specialist dementia nursing team.
The LMA is playing a formal role in Sport United Against Dementia (SUAD), a flagship Alzheimer’s Society campaign which will use the positive power of sport to make a real difference to people affected by dementia, with its CEO Richard Bevan taking a place on the SUAD campaign board.
The Industrial Injuries Advisory Council needs to make a decision at the earliest opportunity as to whether dementia in former sportsmen and women should be classified as an industrial injury.
It is essential that the recognised sports trade unions are actively and meaningfully engaged in negotiations over players’ working conditions to help protect players’ health and safety in both the short and long term.
The NHS should develop a specific clinical pathway for former players who may be living with long term neurological issues. This would enable players to more readily have access to early diagnosis, early treatment to mitigate and delay the devastating effects and the necessary support when needed.
Effective and accessible education for professional athletes is essential so that players are aware of the risks and are able to make informed choices and are aware of how best to minimise the risks. The Player Associations must be involved in the development of these education programmes.
The impact of professional sport upon women’s long-term brain health is an issue which needs separate attention due to the different physiology involved.
There would be benefit for sports stakeholders to provide education for retiring players on the risks of dementia and what steps former professionals can take to reduce the risks and promote improved brain health.
Many Player Association benevolent charities, in particular cricket and rugby union, need to be financially supported so that they can recover from the devastating financial impact of the pandemic and continue to support former players living with dementia.
Government and sport should work together to jointly fund more research into sport, brain injury and dementia.