‘Make CTE an
industrial disease’

With evidence increasingly linking head impacts with neurodegenerative disease, calls for action to protect those exposed to such risks - particularly in contact sports - are growing. 

Here, we speak with Nathan Howarth, executive director of the Concussion Legacy Foundation UK, about how action to tackle safety and attitudes to head injury can lead to positive change

As the research continues to build and develop our understanding of the links between neurodegenerative disease and sport, the need for urgent action to tackle this only becomes more apparent. 

Some of the latest studies, and their findings around Chronic Traumatic Encephalopathy (CTE), are stark and shocking indeed. 

Evidence now proves that the strength and number of impacts a person takes to their brain is directly linked to them developing the devastating brain disease. 

Furthermore, that risk is very much live from the earliest of ages. Evidence also shows irrefutably in the autopsies of brains of young athletes that CTE can take hold well before the age of 30. 

For those playing sport now, that is truly frightening. And for those who have enjoyed a career in elite football or rugby, the thought that symptoms of CTE may develop is a dreadful and cruel unknown about what the future may hold. 

Many former professionals are living with that reality, the horror unfolding for them and their families on a daily basis. Calls are mounting almost by the day that action must be taken to support them, but also to help change the future for others. 

The Concussion Legacy Foundation (CLF) has played a key role in this campaign. With an ambition to cure CTE in sport by 2040 by introducing preventative measures now - particularly at children’s level - the charity is keen to up the ante to make this a reality. 

And for Nathan Howarth, executive director of the CLF UK chapter, its classification as an industrial disease is a vital and much-needed action in its future prevention, as well as in supporting those whose reality it is now. 

“I think this would be an important step and I would like to see this change and for CTE to be classified as an industrial disease,” says Nathan. 

“I know this is slightly difficult, because exposure can sadly come from domestic abuse or from self harm - but if there is a direct correlation to a formal occupation, I think it has to be a key step. 

“And if that means therefore it becomes part of a disease classification, then that means that a brain is examined as a result of that occupation. I think we should be doing that. 

“For those in high risk occupations - sport, but also the military and law enforcement, for example - I think this should be considered as part of an industrial disease classification. 

“We have worked closely with the PFA and the Jeff Astle Foundation on this, and together we are hopeful for the industrial disease classification. I think that would be a very important step.”

Protecting children from CTE

The debate around head impacts for children in sport is a difficult subject to broach, with the need for safety having to also satisfy the desire from young players and their parents for them to experience all aspects of the game. 

But with the evidence mounting around the risk of CTE, governing bodies are intervening. The FA is currently trialling a ban on heading for under-12s, which is optional for local FAs to enforce, the findings of which will inform future safety measures and initiatives. 

While a positive step, Nathan believes the age is still too low. 

“We would probably like to see it taken to 14, which is being done in in the US,” he says. 

“I’ve never seen it as being necessary to head the ball at this age anyway. While it may be seen as being part and parcel of the game in adult football, in the kids’ game, I don’t think it’s an acquired skill they need to have. 

“The brain is still maturing until the age of 25 for males. So it's really key that we are protecting it, because of the functional and personality changes that can occur in that time.

“A lot of our data information comes from American football, because we're behind the curve in terms of our research here, and we know that in American football, obviously, there is a greater risk of those head collisions. 

“But it allows us to model how the paediatric brain adjusts and a young person's brains adjust to those head impacts. If we are finding people aged 17 with CTE, then that's a problem. 

“So if we can decrease the exposure, and take that age up to 14, then I think that’s a positive step. If we can delay the exposure points, then the outcomes will be better as a result of that.”

Although calls have been made for safety measures around heading in football and tackling in rugby to be enforced and therefore compulsory, Nathan is reluctant to go down that route. 

“I'm completely open to the fact that everybody has their autonomy and has the right to make a decision,” he says. 

“I'm keen to see how the (under 12s heading) trial goes, it’s ongoing and will be reviewed. But if we get to a stage where it's a mandatory ban, I think it's always difficult when it's that compulsion. 

“If we want people to have that autonomy, it’s about getting across the clear risk - and there is still that lack of information to parents particularly. I think that is at the root of it.” 

And as well as safety measures, general brain health and wellbeing is another aspect the CLF is keen to promote as a means of keeping young brains safe. 

“I think we should look at keeping our brain healthy full stop, not just what you should and shouldn’t take part in,” says Nathan. 

“Let’s look at positive wellbeing, where we look at nutrition, sleep, socialising, engagement with reading, stretching our cognitive capacity. 

“These are key elements in general brain health, for all ages. And to know that this can also help our brains as we grow older, it makes brain wellbeing an important part of the whole picture.”

Raising awareness and tackling the risks

From its outset in the United States, founder of the CLF, Dr Chris Nowinski, has dedicated himself to education and advocacy around safety. 

Although safety has been revolutionised in many aspects of sport in the US, NFL in particular - with Dr Nowinski being credited as being a pioneer of that - the UK is still a long way behind. 

Whether in medical settings and the recognition of the severity of concussion, or in sport where players have traditionally played on after head injury, attitudes and perceptions have a long way to go. 

Education lies at the heart of that, believes Nathan. 

“We know there is a really disjointed aspect between some understanding of concussion care and brain health,” he says. 

“We need to make sure that allied health professionals, GPs and even people in A&E have the skill set and awareness of concussion to give appropriate signposting as necessary. This is how we are going to make change to patient outcomes.”

Keen to take a lead on making change, the CLF are working with medical institutions to help in the adoption of best practice. 

“We're involved in teaching in a medical school, and also in some of the first medical schools to start doing a comprehensive sports neurology programme,” says Nathan. 

“We are also supporting the Royal College of Emergency Medicine in some of their education - I was on one of their podcasts to give an update regarding the new consensus statement and how that affects clinical practice. 

“It’s also very important that we try to work towards allied health professionals, because they're a key component in the multidisciplinary team, so that is an area we’re keen to work in more widely.”

One initiative which is making particular in-roads in challenging widespread public attitudes to head injury is the CLF’s Media Project, which educates major broadcasters and well-known commentators on appropriate ways to refer to concussion. 

“I see educating the media as a public health tool,” says Nathan. 

“By helping them to understand how to report on concussions in football, and the language to use around that, it starts to shape conversations out there in the public. 

“For example, on Community Shield final day, there was a significant clash of heads which led to the commentary team - who had been through our training - to discuss the protocol and what a player should do if there were symptoms. 

“It reinforces the message in the community that if a head injury takes place, please remove and seek medical attention. 

“We know that football is one of the most watched sporting events, so if we can get messages through via those channels, that’s a very powerful medium.”

The engagement of the media, and its impact on public awareness, is helping to negotiate a landscape that the governing bodies in sport can find difficult, says Nathan. 

“I think they are stuck between a rock and a hard place, because on the one hand, they know a little bit more now, but also they’re being sued by the fact that there have potentially been injuries to former players. So how can they advise and educate? 

“That's where it becomes really difficult. And actually, that's where it starts off with the smaller projects and training the media to talk about it properly. That then starts the conversations elsewhere. 

“I think those smaller conversations are so important, and if they are instigated by what people have seen on TV, then that’s great. The media are such an important part of our strategy both here and in the US, and will continue to be so in us having these conversations moving forward.”