Neurodegenerative disease mortality among former professional soccer players - summary

The official magazine of the Football Medicine & Performance Association

football medicine & performance

Issue 31 Winter 2019/20

Feature

Karen Carney A Pioneer for the Womens’ Game In this issue Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Cautious Return to Play Could Prevent Muscle Injuries FMPA Conference 2020 Neurodegenerative Disease Among Former Footballers

Legal Ţ Education Ţ Recruitment Ţ Wellbeing

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CONTENTS FEATURES

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Injury Mitigation in Team Sports. Part-2: The risk management approach Colin W. Fuller

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What to do and When to do it? The Tricky Question of Specialisation in Youth Football Laura Finnegan

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Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall

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Training the Semi-Professional Footballer Daniel Bernardin, Dylan Mernagh

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Karen Carney A Pioneer for the Women’s Game Sean Carmody

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Wrist Injuries in Goalkeepers Raj Bhatia, Adam Esa, Sam Haines

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Neurodegenerative Disease Mortality Among Former Professional Soccer Players – Summary Emma Russell

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Job Insecurity: Reducing Its Negative Effect on Your Wellbeing Caroline Marlowe

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FMPA Register

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ABOUT

Cautious Return to Play Could Prevent Muscle Injuries in Professional Football Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund

22

Generalised Joint Hypermobility – Why should it be screened for within a football setting?

Adam Johnson

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FMPA Conference 2020

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Understanding and Developing Relationships in the Modern Football Hierarchy Dr Daniel Parnell, Professor Barry Drust

Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk FMPA_Official Officialfmpa fmpa_official LinkedIn: Football Medicine & Performance Association FMPA_Register FMPARegister fmpa_register Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk

Design Oporto Sports www.oportosports.com

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Photography PA Images, FMPA

Project Manager Angela Walton angela.walton@fmpa.co.uk

Contributors Colin W. Fuller, Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall, Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund, Adam Johnson, Dr Daniel Parnell, Professor Barry Drust, Laura Finnegan, Daniel Bernardin, Dylan Mernagh, Raj Bhatia, Adam Esa, Sam Haines, Emma Russell, Caroline Marlowe

Marketing/Advertising Charles Whitney 0845 004 1040

Print Media Village www.media-village.co.uk

Administration Assistant Amie Hodgson amie.hodgson@fmpa.co.uk

COVER IMAGE England’s Karen Carney during the FIFA Women’s World Cup Third Place Play-Off at the Stade de Nice, Nice.

Richard Sellers/PA Wire/PA Images

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NEURODEGENERATIVE DISEASE MORTALITY AMONG FORMER PROFESSIONAL SOCCER PLAYERS – SUMMARY FEATURE / EMMA RUSSELL

Emma Russell FIELD study PhD student University of Glasgow

Background to the FIELD study Neurodegenerative disease in football is an area of research which has, until recently, been largely ignored. This is despite the concerns regarding the risk of neurodegenerative disease in football, which has been driven by the growing recognition of a specific type of neurodegenerative disease, called chronic traumatic encephalopathy (CTE).

Recognition of the pathology in postmortem studies of boxers, American football players, and football (soccer) players has attracted wider attention and made headlines across the globe.

CTE is thought to occur as a direct result of repetitive head injury, which occurs frequently in football, as well as in a variety of other contact sports.

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Prior research has investigated neurodegenerative disease in contact sport athletes, such as American footballers, and boxers. An association between participation in contact sport and neurodegenerative disease is well documented, but often study sample sizes are low, and/or there’s lack of an appropriate comparison group. Regarding football, there is a paucity of robust studies investigating neurodegenerative risk.

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feature What these results do/ do not tell us This study is the first of its kind to provide robust data regarding risk of neurodegenerative disease in football.

However, the study does not inform us about causation. While head impacts have been proposed as a potential causative agent, this conclusion cannot be drawn from the results generated by this study. This study was a starting point in this field of research, and further studies are required to both corroborate these findings, and to further research the cause of these elevated neurodegenerative deaths in former professional football players.

The FIELD Study The FIELD (Football’s InfluencE on Lifelong health and Dementia risk) study is a retrospective cohort study, aiming to better understand the influence of football on long-term health. By using electronic health records, we have been able to obtain death certification, and prescription information for 7,676 former professional footballers, and 23,028 matched population controls. Population controls were matched on a 3:1 basis, they were all male, and were matched on year of birth and degree of social deprivation (using Scottish Index of Multiple Deprivation (SIMD) quintiles).

Study Results Neurodegenerative disease During follow up, 1,180 former footballers died (15.4%), and 3,807 (16.5%) of the general population comparison group died. Neurodegenerative disease mortality was higher in the cohort of former footballers when compared with the matched general population control cohort. Overall, neurodegenerative disease was around 3.5 times greater in former footballers, this was after adjusting for the competing risks of death from heart disease and cancer. We found risk to vary between subtype of neurodegenerative disorder; with risk being greatest for Alzheimer’s disease – which was around 5 times greater in former footballers. Risk was around 4 times greater for motor neurone disease, 3.5 times greater for nonAlzheimer’s dementia, and 2 times greater for Parkinson’s disease. Dementia-related prescriptions were also found to be more commonly prescribed within the former footballer cohort.

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Player position One suggested risk factor for late neurodegenerative disease in former athletes is exposure to repetitive head impacts, which occur in football through heading the football, and/or player-toplayer collisions. It was thought that goalkeepers may have a lower risk of exposure to head injury when compared with outfield players. However, the incidence of neurodegenerative deaths was not different in goalkeepers when compared with outfield players.

Nevertheless, prescriptions for dementia medications were less common among goalkeepers.

Overall mortality Although neurodegenerative deaths were greater in former footballers, results show a reduction in mortality due to other common illnesses. Ischaemic heart disease and lung cancer related deaths were significantly reduced, highlighting some of the health benefits than can result following a career in sport. Former professional footballers were also seen to be living longer, on average, around 3 and a half years longer. We also see a reduction in those dying prior to the age of 70.

Conclusions Overall, we found an increase in deaths due to neurodegenerative disease in our population of former professional footballers, but a reduction in deaths due to other common diseases, such as ischaemic heart disease and lung cancer. We also found an increase in prescriptions for dementia related medications in our former professional footballers.

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It is important to note that this study focused on former footballers who played at a professional level, and therefore these results are not directly applicable to all levels. This research does not allow us to speculate on the risks of playing football at an amateur and/or casual level. At this stage in the research, it is too early to draw conclusions regarding neurodegenerative disease in other sports, and in different levels of play of sport given the diverse mechanism of movement and contact.

CTE, formerly known as dementia pugilistica, is not coded in International Classification of Diseases (ICD) 9 or ICD-10, and therefore we cannot directly comment on the prevalence, either as a primary or secondary cause of disease, of CTE within our footballer cohort.

The future of football and football research Following the insights provided by this study, we hope to see better concussion management in sport, and stricter concussion guidelines, not just for football but for all sport. Reducing risk of unnecessary head injury and head impact should be something that is endorsed.

We have also demonstrated a variety of wider potential health benefits gained following an active career in football, such as reduced incidence of heart disease and lung cancer. Regular sport participation can be of great benefit to many aspects of health. For this reason, we believe participation in sport and regular physical activity should still be greatly encouraged.

The study was funded by both the Football Association (FA), and the Professional Footballers’ Association (PFA), as well as by an NHS Research Scotland Career Researcher Fellowship. The study was published online in the New England Journal of Medicine (NEJM) on 21st October 2019. The full study is available to read on the NEJM website.

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