Squash and Sudden Death

In a recent blog posting, I described the longest squash match ever played. It took place in 1983 between Pakistan’s Jahangir Khan and Gamal Awad of Egypt. In a postscript, I mentioned that Gamal Awad died of a heart attack in 2004 at the early age of 49.

But four years before the match between Khan and Awad, the men’s world-ranked number 13 player, then aged 27, also died of a heart attack. Except this time, it was on court during a tournament match in Australia.

The heart attack victim was Jahangir’s elder brother, Torsam Khan.

Squash and Heart Disease

Seven years after Torsam’s death, I was working as a research scientist for what is now one of the world’s largest pharmaceutical companies. I was also spending an inordinate amount of time playing squash at the company’s sports club which was located on-site just a couple of hundred metres from the research library. And it was while I was browsing the scientific journals in the library that I came across a very interesting article.

It was written by Robin Northcote, Clare Flannigan and David Ballantyne of the Department of Medical Cardiology at the Victoria Infirmary in Glasgow, Scotland. Now, some of you may know that Scotland had (and still does have) one of the highest levels of heart disease in the world, a situation not helped by certain local dietary preferences such as the infamous deep-fried battered Mars bar. So, looking back, the appearance of the Northcote article in the British Heart Journal didn’t come as an enormous surprise to me.

The article had the arresting title, Sudden death and vigorous exercise – a study of 60 deaths associated with squash’. And, by the way, sudden death was defined as “death occurring within 1-24 hours of the onset of symptoms” with the study looking at subjects who had “collapsed while playing squash or within an hour of playing”.

Squash and Psychology

After consulting a few of my fellow squash-playing scientists, I remember citing the article in the squash club newsletter I was then editing. It didn’t generate much, if any, feedback from squash club members even after I’d pinned a copy of the article to the noticeboard outside courts 1 and 2. Anyway, it certainly didn’t result in an exodus from the squash leagues or a noticeable reduction in the number of squash courts booked.

Nearly 25 years after it first appeared, the Northcote et al article is still worth reading. The authors state that, “Many individuals in this study with known medical conditions continued to play squash. Men in middle age seem reluctant to acknowledge that they may be in poor physical condition or health. We and others have noted that sportsmen tend to deny physical infirmity and prodromal symptoms.” Prodromal symptoms (or sets of symptoms) are ones which might indicate the start of a disease before specific symptoms occur.

Most of the people in the study had professional or executive jobs with only 2 of the 60 subjects working in what were regarded as ‘non-sedentary’ jobs. The authors go on to state that, “In addition to a tendency to ignore prodromal symptoms and pre-existing disease at least half of the subjects in this series may have been type A personalities, and this in itself may have increased their risk of sudden death and the development of coronary heart disease”.

Personality typing theory emerged in the 1950s and described two common but contrasting types of people, the highly-strung Type A and the easy-going Type B. These types were regarded as  corresponding to patterns of behaviour that could respectively raise or lower a person’s chances of developing coronary heart disease. Despite its citation in the Northcote study, the theory has since  been regarded as obsolete by many researchers in contemporary health psychology and personality psychology.

But, whatever theory you choose to believe, the overall message remains the same. The risks associated with playing squash and experiencing sudden death originate, at least partially, in the mind.

Exercise-related Sudden Death

In 1994, Northcote published another exercise-related sudden death study in the Oxford Textbook of Sports Medicine (Oxford University Press, Oxford, UK). This time, he looked at a range of sports and activities including running, swimming and soccer, and sudden deaths occurring in the mainland UK, i.e. England, Scotland and Wales. His findings are presented in the following table.

Sport / Activity Number

(Male)

Number

(Female)

Mean Age

at Death

Squash 124 2 44
Soccer 53 32
Swimming 50 6 53
Running 38 1 37
Badminton 26 49
Rugby 14 30

Although squash is at the top of the table, Northcote emphasized that there is a very low statistical risk of sudden death from any sport and that the figures don’t  imply that squash is more dangerous than other sports. Nevertheless, his table does show that a significant number of squash players have probably died unnecessarily, for reasons not unconnected to those proposed in his 1986  article.

Squash and the Mind

So, nothing for squash players to worry about?

Well, in 2004, I had a heart attack. Not something I’d recommend although I’ve certainly found it to be character forming if not personality changing. Unfortunately, or come to think of it fortunately, I wouldn’t have made Robin Northcote’s original study as I hadn’t been playing squash immediately beforehand. But the incident did lead me to take a renewed interest in my own psychological makeup, how it influenced my approach to squash, and how I could change it for the better. In other words, how I could change my mindset to re-connect with squash, feel the passion again – and reduce the risk.

Well, I’m still taking an interest and things certainly do seem to be getting better in all respects. Although I am, of course, still working on it. Promise.