Dazed & Confused - How the World Cup was a disaster when it came to head injuries

Hats off to Germany. They were the best side throughout the World Cup, and deservedly won what has to have been one of the best tournaments to date. There were some extraordinary games in Brazil between 12 June and 13 July, not least the eventual winners 7-1 thrashing of the hosts. Other classics were Nigeria 2, Argentina 3 and Germany 2, Ghana 2, though of the England team, perhaps the best thing to do is say that young players like Raheem Sterling and Daniel Sturridge showed that we might just have a decent future.

But if Brazil 2014 will go down in history as a great and memorable World Cup, it could have been etched in our minds for the wrong reason. I refer not to what might have happened if Luis Suarez had longer teeth, but to the scant understand shown by match officials and administrators of the dangers of head injuries.

Potentially terrible consequences

Three serious incidents occurred in Brazil which could have had terrible consequences for the players involved. The first came when Uruguay beat England 2-1. Álvaro Pereira, the Uruguay defender, was knocked out in a collision with Sterling's knee. As The Times reported: "The Uruguay medical team were seen calling for his substitution, only to be overruled by the player, underlying their helplessness as occupational health physicians."

Next came Argentina's semi-final win over Holland. The superb Javier Mascherano clashed heads with Georginio Wijnaldum towards the half hour mark and showed clear signs of concussion, wobbling on his feet before slumping to the pitch. In spite this, he was allowed to play on.

Then came perhaps the worst incident of all, played out for all the world to see in the final. Christoph Kramer found himself in Germany's starting line-up (making his competitive debut for his country) after an injury in the warm-up to midfielder Sami Khedira. Early into the game, the young player's head smashed accidentally into an Argentinian player. Kramer was visibly disorientated, but was allowed to play on by Germany's medical staff. Fourteen minutes later, he fell to the ground, and was then substituted.

Boorish Lawrenson

Kramer has subsequently said that he couldn't remember anything of the first half the game. He looked awful as he left the pitch, eyes glazed and with a look of 'where am I and what is happening?' etched all over his features. His departure made for a telling counterpoint to the boorish, old-school tough guy commentary of the BBC's Mark Lawrenson, who was persistently sarcastic at players' injuries throughout the tournament and objected to the Argentinian players calling - sportingly - for the ball to be put out of play when Kramer lay stricken. Lawrenson further demonstrated an apparent ignorance of what happens with head injuries when saying, as Kramer groggily waited to come back on, "He's fine. He's jogging round the pitch now."

Thankfully, albeit that he was taken off looking anything but fine just under quarter of an hour later, Kramer does seem to be fine. So, too, was Tottenham goalkeeper Hugo Lloris, despite playing on after a head injury last November. Likewise, we hope, Pereira and Mascherano.

But here's the rub: when it comes to head injuries, we just don't know what damage may have been done. And a minute or two of pitchside assessment, when a player has been knocked out or is as visibly awry as Kramer, is woefully inadequate.

Fifpro, the world players' union, has rightly criticised Fifa for failing to protect the players upon which its tournament depends. The union predicts "a tidal wave [of compensation claims] that will engulf" professional football, unless a protocol regarding concussion is adopted as part of the rules of the game. Radically, and yet sensibly, Fifpro also calls for a review of the laws of the game to compensate a team if it goes down to 10 men while a head injury is being assessed.

Prevention is better than cure

And assessment is crucial. We don't want professional football to end up like the NFL in the United States, or the NHL, where significant class action litigation over head injuries is now a fact of life. Not because of bogus objections to people suing for compensation, but because we don't want to see people needlessly injured. The fact is that a head injury can be fatal; it can lead to Second Impact Syndrome, when a later blow on top of the first one leads to brain damage or death.

Proper attention to head injuries is vital. It is essential that Fifa and the game's national governing bodies around the world take action to ensure that prevention is better than cure - for the fundamental reason that when it comes to a head injury, there may well not be a cure.

Let's give thanks to the continuing recovery of Christoph Kramer and his colleagues - and pray that a professional football match is not one day the scene of a fatal head injury because of governing body negligence.

When it comes to head injuries in sport, prevention is better than cure

The Six Nations rugby championship is upon us. There are just a couple of weeks to go before the annual battle for oval ball supremacy among England, France, Scotland, Ireland, Wales and Italy. History says the trophy will be heading across the channel: each Six Nations championship held the year after a British Lions tour has been won by France. The Lions went on tour in 2013, so maybe the French will be sipping champagne on March 15, when the final matches are played.

I'm no rugby expert. I can't comment on what the form books says this year, but I enjoy watching the Six Nations - the physicality, speed and athleticism of modern rugby is breath-taking. But one thing I can comment on is the need for the best possible care for any player unfortunate enough to suffer a head injury.

Intense negotiations 

This is all the more salient given the news in Tuesday's Guardian about the ongoing legal wrangle between the National Football League and retired NFL players.

Some 4,000 former players sued the NFL, arguing that the NFL knew about the dangers of on-field head injuries long before it did anything, or enough, about them. It was also alleged that the NFL hadn't adequately assisted injured players once their careers were over.

Last August, after two months of what were described as "intense negotiations", the parties reached agreement to settle the litigation. The NFL did not admit liability, but the outline agreement was that the NFL and NFL properties would pay a total of $765 million for injury settlements and medical benefits for retired players. The money would also be used to fund medical and safety research and to pay all litigation expenses.

But as the Guardian reports, the $765m settlement has been rejected by a federal judge. Judge Anita Brody is not happy with the level of financial documentation submitted by the parties. She also doubts that the agreed sum will compensate all the retired NFL players who may one day be diagnosed as suffering from a brain injury. She doesn't doubt that the settlement was reached in good faith, but has, in effect, sent the parties back to the drawing board.

Collective Bargaining Agreements

Professional sport in Britain is conducted on different lines to the United States, where Collective Bargaining Agreements (CBAs) underpin the majority of sports. I am not a sports lawyer, but my understanding of CBAs is that they exist primarily to ensure that salary caps are in place. Salary caps are intended to keep costs down and create parity between clubs. CBAs also, as I understand it, have a considerable bearing on litigation between the leagues and players. Under the American CBA model, players have discernible rights against leagues, whereas here in Britain sportspeople like rugby and football players are employees of their clubs, not the governing leagues.

For this reason, threats by England footballers to strike back in 2003 (when they objected to the treatment of Rio Ferdinand over a missed drug test) may have shown admirable camaraderie but had no legal basis.
Likewise, it may be that officials on high in rugby, football and other UK professional sports look across the pond at the NFL litigation and breathe a tentative sign of relief, in the belief that the absence of CBAs here means that huge class actions against the leagues aren't heading their way.

Perhaps; a sports lawyer will have the answer. But two things are abundantly clear: first, even if the leagues in Britain may not be about to receive a massive head injury class action claim, individual clubs undoubtedly owe a duty of care to their players and could be sued; and secondly, the law is one thing - proper care and due diligence for sportspeople is another.

Prevention is better than cure

So, as we look forward to the Six Nations, it strikes me that we should redouble our efforts to ensure that the government takes the lead and sets an example. It should state unequivocally that clubs must, as a priority, ensure that the best possible awareness of the consequences of head injuries exists among everyone from managers and coaches to players and medical staff. Likewise, schools must take the best possible care of pupils who play sports like rugby and football. And similarly, those in charge of the national teams as they go into the Six Nations.

It's great news, for example, that from next season all professional rugby players will undergo a concussion training programme - but here's hoping the various Six Nations teams will also find time to talk their players about the risks of head injuries before the tournament.

We all want to see a fast, pulsating and impassioned contest for the Six Nations title. We don't want to see players suffering brain injuries that could have been prevented, which lead to litigation. Prevention is better than cure. Here's hoping that British sport - and its administrators all the way up to the government - wake up to the reality of traumatic head injuries suffered by those playing sport.

We need better education and treatment in sport for concussion – and we need it now

For many years I enjoyed playing amateur football. I was never going to be good enough to emulate my heroes, the likes of Peter Osgood or Alan Hudson, but like so many enthusiastic players up and down the country I loved the game. And, again like so many grass roots players, I look back on a few moments from my playing days and shudder.

My retrospective misgivings aren't from memories of open goals missed (or own goals scored). These things happen; if anything, at amateur level they're to be laughed about in the pub afterwards.

No, my misgivings flow from remembering the times when a player suffered a head injury, usually from a clash of heads as two players competed to head the ball. One player would take a severe knock (sometimes both of them, in fact). He'd be on the turf for what seemed an age, only to stagger to his feet and insist that he was well enough to play on. This was almost always what happened. Only rarely did a player on the receiving end of a head injury leave the field of play. Time and again he'd wear his palpable concussion like a badge of honour, and keep going to the end of the game.

Concussion can be fatal

I look back on these incidents and shudder because I realise that collective ignorance – or, perhaps, machismo - had the effect of putting a sportsman's life at risk.

The fact is that concussion can be fatal. It can kill soon after the first signs manifest themselves, or it can kill later in life when the consequence of repeated trauma to the head turns into CTE - chronic traumatic encephalopathy. CTE was formerly known as dementia pugilistica - 'the boxer's disease' - but increasingly studies are revealing that is present in sportspeople from other sports, including American football and ice hockey.

And, as Andy Bull's excellent article in last Sunday's Observer reveals, rugby.  In modern rugby, the dangers of concussion have grown exponentially as the game has evolved, as Bull elegantly puts it, "from a contact sport to a collision sport." Concussion was always a danger in rugby (as it was in football) but today's players are better conditioned than those of yesteryear. Players are bigger, faster, stronger – and they hit a lot harder than they used to. Tackles are now "hits", and YouTube is full of  "greatest hits" from both rugby union and league. But to view, say, this collection of "hits" is not simply an exercise in admiring the bravery of the contemporary player. It is also to come away wholly endorsing the argument in Bull's article: that a sea-change is required in rugby so that players' lives and health are not unnecessarily risked by the modern game's relentless ferocity.

Bull has also written of the tragic story of 14-year-old Ben Robinson, who, on 29 January 2011, was treated on three occasions for blows to the head while playing rugby – and on each occasion sent back onto the pitch to play on. Ben later collapsed and died in hospital in a case of Second Impact Syndrome (SIS). SIS means that the brain swells swiftly and catastrophically after a person suffers a second concussion before symptoms from an earlier one have subsided. SIS is nearly always fatal; if it isn't, it leads to permanent serious disability.

Change has to come from the top

Arguably, today's rugby culture killed poor Ben Robinson, the culture of hitting hard and playing on. SIS certainly killed him. SIS could have caused terrible problems for Hugo Lloris, the Spurs goalkeeper allowed to play on against Everton in a November fixture, and it will continue to cause terrible problems for any number of sportspeople until we succeed in implementing a root and branch change to the way that we regard head injuries in sport.

Head injuries aren't a 'laugh'. It's not amusing to see a player wobble unsteadily, then regain his senses, then play on. It's not a tribute to his fortitude. It's foolhardy. The risks are too great, and, as Dr James Robson, the Scottish rugby union side's chief medical officer, says (in Bull's Observer piece): "When you get a subject as important as this [change] has to come from the top. To me that means the government. They are responsible for the nation's health and that is what we are talking about, the health of the nation's young people." 

Dr Robson is right. So come on, Mr Cameron, what have you got to say? If you could tear yourself away from taking selfies (and worrying about what happens to them) and tweeting about Nigella, perhaps you could endorse the calls for thorough education and treatment in sport for concussion. Those calls, to anyone with any sense, are irresistible. 

When it comes to head injuries in sport, we can learn a lot from looking to America

Hugo Lloris returned to the Tottenham Hotspur line-up on Sunday, but not to the kind of game he'd have liked. The Frenchman has been in the wars lately, with a controversial head injury in his team's fixture against Everton on 3 November. The last thing he would have wanted was to be on the end of a 6-0 drubbing by an effervescent Manchester City frontline.

But at least Lloris was fit to play. Too often, this is not the fate of sportspeople who suffer head injuries. The tragic example of American high school football player Charles Youvella is a case in point. Just over two weeks ago, Youvella died after sustaining a head injury while playing a game in the Arizona Interscholastic Association.

By all accounts a brave and talented player, Youvella's injury came in a Saturday night game, when he was felled by what witnesses described as a 'routine football tackle'. Routine it may have been, but the back of the young man's head hit the ground with considerable velocity. Two days later, on Monday 11 November, Youvella was dead of a traumatic brain injury - notwithstanding, in uncomfortable echoes of the Lloris incident, the fact that immediately after the initial impact he got to his feet and lined up for two more plays.

High stakes

Terrible, premature deaths like Youvella's remind us of the high stakes in many sports, from football, whether American or in the form of 'soccer', to rugby, horse-racing and boxing.

No one would seek to ban people from taking part in sport, the upsides of which embrace an individual's health and sense of self-respect and have a wider societal benefit in fostering discipline, camaraderie and teamwork.

But in many things America shows the way - and last August the National Football League agreed to a $765m (£478) out-of-court settlement with a group of former players who had sued the league for, as The Guardian put it, "its role in hiding or underplaying the effects of brain trauma in the game, while glorifying its violence, a cover-up which has been exposed in a series of recent books and documentaries." Happily - in a development that we should applaud - Microsoft co-founder and Seattle Seahawks owner Paul Allen last week announced that he will fund a two-year, $2.4 million study into whether repeated blows to the head can lead to dementia.

American football is not only sport in the spotlight for its alleged laissez-faire attitude to head injuries. Just this week, 10 players from the National Hockey League began legal proceedings against the league for negligence and fraud, alleging that the sport’s officials should have done more to address head injuries but instead celebrated a culture of speed and violence.

Too robust?

Could the same thing happen here? British sporting culture prides itself on being robust, on taking the knocks and getting up and playing on. But 'being robust' can have deadly consequences. Hugo Lloris was, thankfully, lucky; the next footballer encouraged to play on after a head injury might not be.

The key message is that prevention is better than cure - especially when it comes to brain injuries. We must remain vigilant and astute to the dangers of 'getting on with it'; so too must we keep a watchful eye on medical developments in this complex area. And, looking across the pond, we could sensibly take a leaf out of Paul Allen's book - at the same time as hoping that British sportspeople don't find themselves forced to take class actions to achieve recompense for traumatic head injuries.

Natalie Sharp, our determined young boxer

This time last year, almost to the day, I wrote about boxing. I wondered whether the case against boxing was too strong to ignore, not least because of the views of the likes of Peter McCabe, the chief executive of Headway. For Peter, the case against boxing was clear-cut: "Repeated blows to the head causes chronic brain injury," he told me. "Anyone taking up boxing is needlessly risking their health."

Since then, though, Britain has hosted the Olympics, and many of us were inspired by the efforts of our pugilists. Haringey-based Nicola Adams especially put a smile on many faces when she became the first woman to win an Olympic boxing Gold medal. Her joy and enthusiasm were truly infectious.

I've also encountered boxing closer to home, too. One of Spencers' employees, Natalie Sharp, is a dedicated boxer. By day, Natalie is a litigator in our Chesterfield office; many nights a week, she trains at the renowned Unity ABC in Wincobank, Sheffield. Chief coach Brendan Ingle has a reputation that goes beyond boxing, so much so that even people who aren't so sure about the noble art - like yours truly - have heard of him. His gym, which produced Prince Naseem Hamed and Herol 'Bomber' Graham, is a byword for hard work, discipline and success.

Natalie has some serious ambitions. "I want to compete in the next Olympics in Rio, and I want to be the first female professional boxer to come out of the Ingle Camp," she tells me. To fulfil her dreams, Natalie trains at least three nights a week at Unity with Jon Keeton, a former cruiserweight professional boxer. "I love the atmosphere of the gym," she says, "and Jon is a great trainer. I've got a huge amount of respect for him." And when she's not in the boxing gym, Natalie is out running and working on other aspects of her fitness. "All in all, I train six nights a week, minimum," she says.

Before she took up boxing Natalie was a karate expert. She took up Wado Ryu when she was eight, and became a black belt, third dan. She also learnt how to kickbox before, two years ago, switching exclusively to boxing. Now 23, Natalie's previous martial arts experience means that she has it tougher than most when it comes to competing in Amateur Boxing Association (ABA) bouts: "Because I've got a lot of martial arts experience I've had to fight opponents who've already got quite a few fights under their belts rather than novices," she reveals. Due allowance should be made for this in looking at Natalie's record of two wins and two defeats from four ABA fights. "One of my opponents had had 10 fights, another had had 16," she tells me.

But Natalie doesn't bemoan her fate. She chalks up each contest as invaluable experience towards the fulfilment of her goals. She's a determined young woman who exudes a quiet and steely confidence as much as she is clearly athletic and physically very capable.

So, has Natalie, Spencers' very own boxer, changed my mind? Am I now a convert to the world of southpaws, rope burns and TKOs?

I don't think so. On a personal level I know that boxing isn't for me, and I continue to have reservations about it in a wider sense. But so long as it remains lawful, I would always respect an individual's decision to lace up a pair of gloves and step up to the mark. I think, as a society, that we should respect the rights of others to make their own choices. And when I think about just how hard Natalie works at realising her ambitions, in this toughest of arenas, I also take my hat off to anyone who's made of the same stuff.

I'll write about Natalie's progress from time to time, so do check in to see how she's doing.