Hughes’ death renews debate on head injuries and protection

Cricketer Phillip Hughes' death after taking a ball to the neck has once again cast light on brain injuries in sport. A spate of accidents has forced sporting bodies to reassess the importance of protection.

Phillip Hughes died two days after being put in an induced coma after he was struck in the neck with a cricket ball. Scott Barbour / Getty Images

For cricketer Phillip Hughes, a blow to the neck was fatal. For Formula One legend Michael Schumacher, a skiing accident a year ago has left him with life-changing injuries.

Both accidents fuel the continuing debate about whether sportsmen have enough protection against head injuries.

Hughes, 25, who played for Australia, died two days after being put in an induced coma, the same measure taken when Schumacher struck his head on a rock after falling off-piste while skiing with his son in the French Alps in December last year.

While Schumacher survived the coma, the damage to Hughes’s brain was too great. He died on November 27.

Cricket balls weigh between 155.9 grams and 163g, and travel at speeds of up to 150kph.

In this instance, the ball bounced before hitting Hughes in a vulnerable area at the base of his skull on his left side, just behind the grille of his helmet. The pressure of the hit tore his vertebral artery, causing bleeding in his brain.

Masuri, the UK helmet maker, said it was reviewing television footage to assess what had happened. Hughes, the company said, was wearing last year’s model, not the latest, which “does afford batsmen extra protection in this region”.

Last month, a Pakistani cricketer was taken to hospital in Abu Dhabi with a fractured skull after being hit on the helmet with a ball.

Ahmed Shehzad was hit on the side of the helmet and dropped his bat before collapsing to the ground. He was under observation for two days and was ruled out of the rest of the Test series against New Zealand.

Then, just four days after Hughes’s death on November 27, an umpire and former captain of the Israeli national cricket team, Hillel Oscar, died after being hit in the neck with a ball. Umpires do not wear helmets.

Cricket is only one of many sports where helmets are compulsory. In American football, ice hockey, skiing, some levels in boxing and most other high-speed and contact sports, sportsmen all wear protective headgear.

Even so, concussion remains the leading cause of brain damage in sports, say researchers at the Cleveland Clinic.

Concussions happen when the brain hits the inner walls of the skull, usually after a hard knock to the head, neck or upper body.

The injury affects brain function, causing symptoms such as headaches, temporary loss of consciousness, dizziness, nausea or slurred speech.

It can also cause bleeding in the brain, which if serious enough, means the fluid needs to be drained or the skull opened to release pressure.

“In the US, we have seen a significant increase in reports of concussion over the past 10 years,” says Dr Andrew Russman, a neurologist at the Cleveland Clinic’s concussion centre. “This has been largely attributed to increased awareness, rather than an actual increase in injuries.”

Football accounts for the “greatest individual risk of concussion”, Dr Russman says, as many as basketball, baseball, wrestling and softball combined.

In March last year, researchers from the Lerner Research Institute revealed that American football players could suffer long-term brain changes even if they never receive a concussion. Estimates indicate that up to 40 per cent of players experience a concussion each year.

The study of 67 college football players revealed that the more times a player was hit in the head, the higher the level of a brain protein that leaks into the blood after a head injury, even if the player does not suffer concussion.

“Much attention is being paid to concussions among football players and the big hits that cause them, but this research shows that more common, sub-concussive hits appear to cause damage too,” said Damir Janigor, the director of cerebrovascular research at the Lerner Research Institute.

The research team said finding the protein S100B in the blood indicated damage to the blood-brain barrier. When it leaks from the brain into the blood stream, the body’s immune system sees it as a foreign invader and releases auto-antibodies against it.

These seep back into the brain through the damaged barrier, attacking brain tissue and leading to long-term brain damage.

Body contact and playing in a game did not affect the levels in the blood, indicating it was a direct result of a trauma to the head.

The Cleveland Clinic’s Lu Ruvo Centre for Brain Health in Las Vegas is researching the brain function of active and retired boxers and mixed martial arts fighters.

The four-year Professional Fighters Brain Health study, begun in 2011, has revealed that there is a "relationship between the number of fights and decline in the volume of certain areas of the brain", and that these changes are not seen until after about five years of professional fighting.

Even sports that do not use helmets are having to rethink their attitude to head injuries. This year the English Football Association (FA) announced new guidelines for head injuries after being criticised for lax rules that put players in danger.

Starting this season, the rules put the decision about whether a player can return to the pitch after a head injury solely in the hands of the team’s doctor. If there has been a “confirmed or suspected period of loss of consciousness”, the player must sit the rest of the game out.

It also created new “return to play” rules that state players who suffer a head injury should be psychometrically tested every 48 hours after the incident, and clinically assessed every day. They should not return to play until at least six days have passed.

In August, the FA said the medical committee had been reviewing head injuries and concussion in the game since last year to “enhance the existing guidelines for football in England”.

“Managers, players and clubs need to understand the risks associated with head injuries,” said Dr Ian Beasley, the chief of the FA’s medical committee. “The advice of medical professionals is key in this area, and while we have developed processes to deal with many types of injury this is an area that has perhaps needed some more scrutiny.”

Professional players will also undergo screening at the start of every season, as is the case in rugby union and American football, so that medics can measure the effects of any brain injury.

If a head injury occurs but the player remains conscious, team doctors should use a concussion recognition tool to asses whether he or she should be removed from the pitch.

The introduction of the new guidelines was accompanied by a very public campaign backed by some of the country’s top players, including Steven Gerrard, Rickie Lambert and Leighton Baines.

Last season the Tottenham Hotspur goalkeeper, Hugo Lloris, was allowed to return to play after being knocked unconscious in a collision with another player’s knee. The decision by the club to allow him to continue was heavily criticised by some medical experts.

The debate surrounding head injuries in football has been long-running.

In October 2006, an incident at an English Premier League match reignited the debate when the Chelsea goalkeeper, Petr Cech, collided with an opposition player in the first minute of the game.

He received medical treatment on the pitch for a few minutes before crawling off on all fours and finally being carried off on a stretcher.

Cech had suffered a fractured skull that nearly cost him his life. He returned to the game three months later and even now wears a rugby-style helmet when playing.

Luke Griggs, the director of communications at Headway, a UK brain injury association, says sports administrative bodies and sportspeople are becoming more aware.

“Head injuries have always been a risk factor in contact sports,” Mr Griggs says. “What we are seeing, however, is an increase in awareness and understanding of the effect even a seemingly minor and innocuous-looking head injury can have.”

The registered charity works with people who have suffered a brain injury, as well as carers, health professionals and lawyers. It campaigns for better support and resources, and offers information to those with sports-related head injuries.

“Collisions and accidents will always occur in sport and it is impossible to remove all risk – as indeed it is impossible to remove all risk from life itself,” Mr Griggs says, adding that it is essential that sports organisations continue to put the welfare of players above everything else.

“A great deal of work is going into strengthening protocols for concussion in sport and this has to be welcomed. However, what is very clear is that more work is still needed to ensure the rules in all sports are strong enough and fully adhered to.”

Dr Russman says that while there have been improvements in guidelines for managing sport-related concussions, the pace of change is slow because of lack of evidence to support scientific changes in equipment or rules.

Professional sports bodies are trying to find a “happy medium” where play can continue safely. “No helmet, equipment, mouthpiece or technology will completely prevent sports concussions from occurring,” Dr Russman says.

“However, we can reduce the severity and consequences of head injury by making an early diagnosis of symptoms, and removing an athlete from play before further injury occurs.”