CNN  — 

In 2002, at just 59, former British footballer Jeff Astle choked to death.

He’d been diagnosed with early onset Alzheimer’s disease before his death.

But 12 years later, Dr. Willie Stewart, a neurosurgeon, concluded that Astle had actually been suffering from the degenerative brain disease, chronic traumatic encephalopathy (CTE) from repeatedly heading footballs.

“Unless you’ve seen it and lived it, it’s so difficult to try and describe it,” Dawn Astle told CNN Sport, as she remembered looking after her father Jeff and coping with his deteriorating health. “It was just the most brutal, brutal thing I’ve ever seen in my life.”

WBA's Jeff Astle of West scores against Wolves in October 1964.


Back in 2002, January 19 was supposed to be a day of celebration for the Astle family. It was Dawn’s 34th birthday.

“We’d just buried my grandmother – my mum’s mum – the day before,” recalls Dawn.

“I can see my dad now coming through the front door with mum. He didn’t really walk properly, he shuffled and walked with a stoop, his skin looked gray and his face was gaunt. He was 59 but, I kid you not, he looked 159.

“And it was while we were eating this tea, while Dad was sitting at the table, that he started to cough.

“I remember we helped him up off his chair but his legs kept giving way. With everybody in the house it was quite stuffy so we took him outside. But he just kept coughing and just coughing and you could tell it was getting worse.

“We were screaming, literally screaming, at him to spit the food out. We didn’t know whether he had food in it because he’d got his teeth gritted together and he wouldn’t open his mouth.

“We were begging with him, pleading with him, ‘spit it out, spit it out’ but he just wouldn’t do it. His legs eventually gave way so we lay him down.

“It was just the most horrific thing because, not just what was happening in front of your eyes, but because you were so helpless, you just couldn’t do anything. He basically choked to death in front of us, you know mum, me and my sisters.”

Liverpool's Mo Salah suffered concussion in a Premier League match against Newcastle.

Red flags

Head injuries in football are very much in the news at the moment.

Star striker Mo Salah was unable to play for Liverpool in its recent Champions League semifinal second leg against Barcelona after suffering a concussion during a Premier League match against Newcastle.

Tottenham Hotpsur defender Jan Vertonghen was left bloodied and dazed after colliding with teammate Toby Alderweireld as the pair challenged Ajax goalkeeper Andre Onana for the ball in the other Champions League semifinal in the first leg.

After being treated on the field for some time, Vertonghen was initially cleared to continue playing, before staggering to the touchline just moments later.

There, he stood retching and had to be helped from the field by the team’s backroom staff.

Tottenham said its medical team strictly followed the English Football Association concussion guidelines in caring for Vertonghen. In a statement, the club said: “Following testing he was judged to be alert and answered all questions correctly and lucidly, deeming him fit to return to the field of play.”

Vertonghen then underwent further tests and was seen by an independent neurologist who concluded the Belgian international defender hadn’t suffered a concussion.

World governing body FIFA has a series of red flags that club doctors should observe when examining players suspected of suffering concussion, for example, checking whether they are suffering from double vision or have lost consciousness.

But Chris Nowinski, co-founder and CEO of the Concussion Legacy Foundation, told CNN Sport that “international soccer’s concussion protocols are the worst in the world. Their substitution rules are archaic and not based on current clinical care for concussion.”

Responding to Nowinski’s comments, FIFA said it “regularly monitors the situation of head injuries, maintaining constant contact with current and on-going studies on this matter and reviewing our protocols.

“As mentioned in the concussion module of FIFA’s Emergency Medical Manual, ‘if, at any stage of the concussion assessment, the medical team cannot make a definite decision regarding whether concussion is present or not and a doubt exists,’ it is recommended that ‘when in doubt, sit the player out’ and he or she should be removed from play.”

Astle scored 174 goals for West Brom.

‘Ref, is this the final?’

In the 2014 FIFA World Cup final, Germany’s Christoph Kramer was allowed to continue playing after a clash of heads, only to be forced off by suspected concussion later in the game.

“Shortly after the blow, Kramer came to me asking: ‘Ref, is this the final,’” World Cup final referee Nicola Rizzoli later told La Gazzetta dello Sport.

At last year’s World Cup in Russia, Morocco’s Nordin Amrabat suffered a concussion during a defeat against Iran, only to play five days later in headgear, which he discarded early on in the match. After Amrabat’s return, Morocco manager Herve Renard described the former Watford player as a “warrior.”

At the time Morocco team doctor Abderazzak El Hifti was criticised on social media for patting Amrabat on the cheeks as he treated the player.

“We received a letter from FIFA that reminds us of the recommendations to follow […] we respected them point by point, our intervention was correct,” El Hifti said in a video sent to media by the Moroccan Federation.

“I asked him five questions and he could only answer one, I saw clear symptoms of cerebral concussion. We can never make a decision that would put a player’s health at risk.”

But the decision to put Amrabat back on the field didn’t follow FIFA’s suggested protocol, which calls for a six-day concussion break.

However, the governing body does not have the authority to officially enforce the guideline. The concussion protocols of European governing body UEFA and national federations like the English Football Association closely mirror FIFA’s guidelines.