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Lin CL, DeMessie B, Ye K, Hu S, Lipton ML. Neck strength alone does not mitigate adverse associations of soccer heading with cognitive performance in adult amateur players. PLoS One 2024; 19:e0302463. [PMID: 38753699 PMCID: PMC11098408 DOI: 10.1371/journal.pone.0302463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 04/03/2024] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVES Soccer heading is adversely associated with neurocognitive performance, but whether greater neck strength or anthropometrics mitigates these outcomes is controversial. Here, we examine the effect of neck strength or anthropometrics on associations of soccer heading with neurocognitive outcomes in a large cohort of adult amateur players. METHODS 380 adult amateur league soccer players underwent standardized measurement of neck strength (forward flexion, extension, left lateral flexion, right lateral flexion) and head/neck anthropometric measures (head circumference, neck length, neck circumference and neck volume). Participants were assessed for heading (HeadCount) and cognitive performance (Cogstate) on up to 7 visits over a period of two years. Principal components analysis (PCA) was performed on 8 neck strength and anthropometric measures. We used generalized estimating equations to test the moderation effect of each of the three PCs on 8 previously identified adverse associations of 2-week and 12-month heading estimates with cognitive performance (psychomotor speed, immediate verbal recall, verbal episodic memory, attention, working memory) and of unintentional head impacts on moderate to severe central nervous system symptoms. RESULTS 3 principal components (PC's) account for 80% of the variance in the PCA. In men, PC1 represents head/neck anthropometric measures, PC2 represents neck strength measures, and PC3 represents the flexor/extensor (F/E) ratio. In women, PC1 represents neck strength, PC2 represents anthropometrics, and PC3 represents the F/E ratio. Of the 48 moderation effects tested, only one showed statistical significance after Bonferroni correction, which was not robust to extensive sensitivity analyses. CONCLUSION Neither neck strength nor anthropometrics mitigate adverse associations of soccer heading with cognitive performance in adult amateur players.
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Affiliation(s)
- Chin Lun Lin
- Montefiore Medical Center, Bronx, New York, United States of America
| | - Bluyé DeMessie
- Department of Neuroscience, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Kenny Ye
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Systems and Computational Biology, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Shanshan Hu
- The Epoch Times, New York, New York, United States of America
| | - Michael L. Lipton
- Department of Radiology, Columbia University Irving Medical Center, New York, New York, United States of America
- Department of Biomedical Engineering, Columbia University, New York, New York, United States of America
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Kern J, Gulde P, Hermsdörfer J. A prospective investigation of the effects of soccer heading on cognitive and sensorimotor performances in semi-professional female players. Front Hum Neurosci 2024; 18:1345868. [PMID: 38404611 PMCID: PMC10884128 DOI: 10.3389/fnhum.2024.1345868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/15/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction Repetitive head impacts (RHI) from routine soccer (football) heading have been suggested to contribute to the long-term development of neurodegenerative disorders. However, scientific evidence concerning the actual risk of these RHI on brain health remains inconclusive. Moreover, female athletes-despite a presumably increased vulnerability toward the effects of RHI-are largely underrepresented in previous approaches. Therefore, our aim was to prospectively investigate the effects of heading on cognitive and sensorimotor performances, health perception, and concussion symptoms in semi-professional female soccer players. Methods An extensive test battery was used to assess cognitive and sensorimotor performances as well as health status (SF-36) and concussion symptoms (SCAT3) of a total of 27 female soccer players (22.2 ± 4.2 years) and 15 control subjects (23.2 ± 3.0 years) before and after one-and-a-half years. Throughout this period, soccer players' heading exposure was determined using video analysis. Results Subgroup comparisons (control [n = 12], low exposure [n = 7], high exposure [n = 8]) showed no time-dependent differences in SF-36 or SCAT3 scores. Similarly, across most behavioral tests, soccer players' performances evolved equally or more favorably as compared to the control subjects. However, there were significant effects pointing toward slightly negative consequences of heading on aspects of fine motor control (p = 0.001), which were confirmed by correlation and multiple regression analyses. The latter, further, yielded indications for a relationship between heading exposure and negative alterations in postural control (p = 0.002). Discussion Our findings do not provide evidence for negative effects of soccer heading on female players' health perception, concussion symptoms, and cognitive performances over the course of one-and-a-half years. However, we found subtle negative alterations in fine motor and postural control that could be attributed to heading exposure. Other factors, like the number of previous head injuries, were not linked to the observed changes. Given the reduction of our initial sample size due to player fluctuation, the results need to be interpreted with caution and validated in larger-scale studies. These should not only focus on cognitive outcomes but also consider sensorimotor changes as a result of RHI from soccer heading.
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Affiliation(s)
- Jan Kern
- Chair of Human Movement Science, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
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Hageman G, Hageman I, Nihom J. Chronic Traumatic Encephalopathy in Soccer Players: Review of 14 Cases. Clin J Sport Med 2024; 34:69-80. [PMID: 37403989 DOI: 10.1097/jsm.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/22/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Exposure to repetitive sports-related concussions or (sub)concussive head trauma may lead to chronic traumatic encephalopathy (CTE). Which impact (heading or concussion) poses the greatest risk of CTE development in soccer players? DESIGN Narrative review. SETTING Teaching hospital and University of Applied sciences. PATIENTS A literature search (PubMed) was conducted for neuropathologic studies in the period 2005-December 2022, investigating soccer players with dementia and a CTE diagnosis, limited to English language publications. 210 papers were selected for final inclusion, of which 7 papers described 14 soccer players. ASSESSMENT Magnetic resonance imaging studies in soccer players show that lifetime estimates of heading numbers are inversely correlated with cortical thickness, grey matter volume, and density of the anterior temporal cortex. Using diffusion tensor imaging-magnetic resonance imaging, higher frequency of headings-particularly with rotational accelerations-are associated with impaired white matter integrity. Serum neurofilament light protein is elevated after heading. MAIN OUTCOME MEASURES Chronic traumatic encephalopathy pathology, history of concussion, heading frequency. RESULTS In 10 of 14 soccer players, CTE was the primary diagnosis. In 4 cases, other dementia types formed the primary diagnosis and CTE pathology was a concomitant finding. Remarkably, 6 of the 14 cases had no history of concussion, suggesting that frequent heading may be a risk for CTE in patients without symptomatic concussion. Rule changes in heading duels, management of concussion during the game, and limiting the number of high force headers during training are discussed. CONCLUSIONS Data suggest that heading frequency and concussions are associated with higher risk of developing CTE in (retired) soccer players. However based on this review of only 14 players, questions persist as to whether or not heading is a risk factor for CTE or long-term cognitive decline.
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Affiliation(s)
- Gerard Hageman
- Department of Neurology, Medisch Spectrum Twente, Hospital Enschede, Enschede, the Netherlands; and
| | - Ivar Hageman
- Saxion University of Applied Sciences, Enschede, the Netherlands
| | - Jik Nihom
- Department of Neurology, Medisch Spectrum Twente, Hospital Enschede, Enschede, the Netherlands; and
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Peek K, Duffield R, Cairns R, Jones M, Meyer T, McCall A, Oxenham V. Where are We Headed? Evidence to Inform Future Football Heading Guidelines. Sports Med 2023; 53:1335-1358. [PMID: 37285067 PMCID: PMC10289964 DOI: 10.1007/s40279-023-01852-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 06/08/2023]
Abstract
Given the scientific and public concern regarding the short-, medium- and long-term consequences of heading on brain health, being proactive about developing and implementing guidelines that help reduce the burden (volume, impact magnitude and injury risk) of heading in young and beginner players appears justified. This narrative review explores the evidence underpinning strategies that could be incorporated into future heading guidelines to reduce heading burden in players across all levels of football. A four-step search strategy was utilised to identify all data-based papers related to heading in football. Eligibility criteria for inclusion were: (1) original data, (2) study population included football players, (3) outcome measures included one or more of the following: number of headers, measurement of head acceleration during heading, or head/brain injury incidence, and (4) published in English or English translation available. In total, 58 papers were included that outlined strategies based on (1) game or team development, (2) player skill development and (3) equipment. In particular, greater emphasis existed for small-sided games (particularly in young players) where fewer headers are observed when compared with the conventional 11 versus 11 game, as well as reducing headers from goal kicks and corners. Evidence also existed for developing a heading coaching framework that focusses on technical proficiency as well as neuromuscular neck exercises integrated into general injury reduction exercise programs, enforcement of rules related to deliberate head contact and using lower-pressure match and training balls. To mitigate potential risks of heading on brain health, a number of pragmatic strategies have been examined in scientific studies and may be considered as part of future heading guidelines.
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Affiliation(s)
- Kerry Peek
- Discipline of Physiotherapy, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Rob Duffield
- School of Sport, Exercsie & Rehabilitation, Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
- Football Australia, Sydney, NSW Australia
| | - Ross Cairns
- Newcastle Sports Medicine, Warners Bay, NSW Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Mark Jones
- Football Australia, Sydney, NSW Australia
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrücken, Germany
| | - Alan McCall
- School of Sport, Exercsie & Rehabilitation, Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
- Football Australia, Sydney, NSW Australia
| | - Vincent Oxenham
- School of Psychological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW Australia
- Department of Neuropsychology, Royal North Shore Hospital, Sydney, NSW Australia
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Peek K, Versteegh T, Veith S, Whalan M, Edwards S, McKay M, Gardner AJ. Injury-Reduction Programs Containing Neuromuscular Neck Exercises and the Incidence of Soccer-Related Head and Neck Injuries. J Athl Train 2023; 58:519-527. [PMID: 36645836 PMCID: PMC10496449 DOI: 10.4085/1062-6050-0340.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
CONTEXT Concern is growing among soccer players, coaches, and parents regarding head and neck injuries, including concussion, particularly from heading a ball. Thus, we need to explore soccer-specific head injury risk-reduction initiatives. One such initiative is to condition the neck musculature of young players by adding neuromuscular neck exercises to existing injury-reduction exercise programs. OBJECTIVE To investigate the effect of neuromuscular neck exercises completed as part of an injury risk-reduction exercise program on the incidence of soccer-related head and neck injuries in adolescent soccer players. DESIGN Prospective cohort study. SETTING Two sports high schools and 6 soccer clubs during the 2021 soccer season. PATIENTS OR OTHER PARTICIPANTS A total of 364 male and female soccer players, aged 12 to 18 years. INTERVENTION(S) Members of 1 sports high school and 2 soccer clubs performed neuromuscular neck exercises as part of an injury-reduction program during training (neck training group). Members of another sports high school and 4 soccer clubs performed an injury-reduction program but without neck exercises (comparison group). MAIN OUTCOME MEASURE(S) Self-reported injury data were collected from each player at the end of the season and used to calculate incidence rate ratios (IRRs) with 95% CIs. RESULTS In total, 364 players completed the study, including 146 players in the neck training group and 218 players in the comparison group. Despite players in the neck training group being less likely to self-report a concussion (IRR = 0.23; 95% CI = 0.03, 1.04) and pain on heading a ball (IRR = 0.62; 95% CI = 0.34, 1.07), only a lower incidence of possible concussive events (IRR = 0.38; 95% CI = 0.14, 0.90; P < .05) was significant. CONCLUSIONS Integrating neuromuscular neck exercises into injury-reduction exercise programs has the potential to reduce the risk of adolescent soccer players sustaining a possible concussive event, concussion, or pain on heading a ball.
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Affiliation(s)
- Kerry Peek
- Discipline of Physiotherapy, University of Sydney, New South Wales, Australia
| | | | - Stella Veith
- Centre of Medical and Exercise Physiology, School of Medicine, University of Wollongong, New South Wales, Australia
| | - Matt Whalan
- Centre of Medical and Exercise Physiology, School of Medicine, University of Wollongong, New South Wales, Australia
| | - Suzi Edwards
- Discipline of Physiotherapy, University of Sydney, New South Wales, Australia
| | - Marnee McKay
- Discipline of Physiotherapy, University of Sydney, New South Wales, Australia
| | - Andrew John Gardner
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
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LANGDON SHARI, GOEDHART EDWIN, OOSTERLAAN JAAP, KÖNIGS MARSH. Heading Exposure in Elite Football (Soccer): A Study in Adolescent, Young Adult, and Adult Male and Female Players. Med Sci Sports Exerc 2022; 54:1459-1465. [PMID: 35482757 PMCID: PMC9390232 DOI: 10.1249/mss.0000000000002945] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aims to quantify heading exposure in real-life elite football at the level of individual male and female adolescents, young adults, and adults. METHODS Heading exposure was determined by video analysis in combination with a structured electronic registration tool and observation training, to comprehensively register heading characteristics. Characteristics of heading events were registered in 116 official matches (96 male, 20 female) of Dutch national teams. RESULTS Mean exposure for male players based on full match participation was 4.2 headers, with maximum heading exposure at 10.6 headers. Mean heading exposure was higher in adult than adolescent players ( P = 0.049), whereas maximum heading exposure was higher for adult than for young adult players ( P = 0.045). Maximum heading exposure was higher in male than in female players ( P = 0.015). Defenders had the greatest mean and maximum heading exposure ( P < 0.001). Longer flight courses of the ball had greater contribution to mean and maximum heading exposure than shorter courses ( P < 0.01). Frontal headers had greater contribution to exposure than other points of contact on player's head ( P < 0.001), whereas linear headers had greater contribution than rotational headers ( P = 0.016). Defensive headers had greater contribution to exposure than other heading types ( P < 0.014). Unintentional head contacts in elite football players were, in most cases (80%), not related to heading situations. CONCLUSIONS This study provides real-life quantifications of mean and maximum heading exposure in elite football, with strong relevance for policy makers and researchers. The results highlight the roles of player and heading characteristics in heading exposure, informing current discussions on the role of heading in football.
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Affiliation(s)
- SHARI LANGDON
- Emma Neuroscience Group, Department of Pediatrics, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, THE NETHERLANDS
- Football Medical Centre, Royal Netherlands Football Association (KNVB), Zeist, THE NETHERLANDS
- Amsterdam Reproduction and Development Research Institute, Amsterdam, THE NETHERLANDS
| | - EDWIN GOEDHART
- Football Medical Centre, Royal Netherlands Football Association (KNVB), Zeist, THE NETHERLANDS
| | - JAAP OOSTERLAAN
- Emma Neuroscience Group, Department of Pediatrics, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, THE NETHERLANDS
- Amsterdam Reproduction and Development Research Institute, Amsterdam, THE NETHERLANDS
| | - MARSH KÖNIGS
- Emma Neuroscience Group, Department of Pediatrics, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, THE NETHERLANDS
- Amsterdam Reproduction and Development Research Institute, Amsterdam, THE NETHERLANDS
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Abstract
Purpose: To quantify the incidence and characteristics of purposeful headers and unintentional head impacts in football (soccer) in boys' football over three seasons.Methods: This retrospective longitudinal study analysed purposeful headers and unintentional head impacts collected over three seasons (under-10 to under-12) using match video analysis from boys' team in Australia. Total headers and head impacts, as well as incidence rate (IR) per 1000 match-hours for different match characteristics, were calculated.Results: Total number of headers and heading IR increased significantly (r = 0.99) with age from under-10 (n = 29; IR: 483) to under-12 (n = 149; IR: 1515). All but three players (87%) were observed to head the ball at least once during a season (mean: 10, range 0-25) with the accumulative number of headers performed by out-field players over three seasons ranging from 6 to 40. Players in defensive positions (n = 121) headed the ball more frequently than midfielders (n = 83) or attackers (n = 53). Five (IR: 22) unintentional head impacts were observed, of which four required medical attention.Conclusion: Although the number of headers performed by young players in under-10 to under-12 age groups was low, the range of headers performed by individuals varied greatly. These results could be used to guide age-specific heading coaching practices.
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Affiliation(s)
- Kerry Peek
- Discipline of Physiotherapy, University of Sydney, Lidcombe, Australia
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrücken, Germany
| | - Florian Beaudouin
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrücken, Germany
| | - Marnee McKay
- Discipline of Physiotherapy, University of Sydney, Lidcombe, Australia
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McCunn R, Beaudouin F, Stewart K, Meyer T, MacLean J. Heading in Football: Incidence, Biomechanical Characteristics and the Association with Acute Cognitive Function-A Three-Part Systematic Review. Sports Med 2021; 51:2147-2163. [PMID: 34129222 DOI: 10.1007/s40279-021-01492-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is growing concern surrounding the role of repetitive sub-concussive head impacts, such as football heading, on brain health. OBJECTIVES Three questions were addressed while only considering studies that observed heading exposure directly: (1) how frequently does heading occur within football training and matches, (2) what are the biomechanical characteristics of heading, and (3) is cognitive function affected by heading? METHODS This review followed the steps described in the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Electronic databases including MEDLINE and SPORTDiscus were searched from the earliest entry to July 2020. Studies that reported independently quantified heading exposure, biomechanical characteristics of heading or the relationship between heading and cognitive function were included. Data were extracted and used to populate summary tables with reference to each research question. RESULTS Heading incidence ranged between one to nine headers per player per match. The number of headers observed in small-sided games during training varied depending on the exact format used but generally speaking ranged between zero to one per player per game. The three most commonly reported biomechanical variables were head acceleration, head rotational velocity and overall movement kinematics during the heading action. Average head acceleration ranged from approximately four to 50 g. Nine out of 12 included studies did not observe a negative impact on cognitive test performance following exposure to heading and while three did, these negative effects were limited to specific outcome measures: reaction time and memory function. CONCLUSION The current weight of evidence summarised herein does not support the notion that heading is deleterious to cognitive performance in the short term; however, this conclusion is tentative due to methodological shortcomings in the existing evidence base.
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Affiliation(s)
- Robert McCunn
- Heart of Midlothian Football Club, Tynecastle Park , Edinburgh, EH11 2NL, UK.
| | - Florian Beaudouin
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrücken, Germany
| | - Katy Stewart
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Hampden Sports Clinic, Glasgow, UK
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrücken, Germany
| | - John MacLean
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Hampden Sports Clinic, Glasgow, UK
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Verduyn C, Bjerke M, Duerinck J, Engelborghs S, Peers K, Versijpt J, D'haeseleer M. CSF and Blood Neurofilament Levels in Athletes Participating in Physical Contact Sports: A Systematic Review. Neurology 2021; 96:705-715. [PMID: 33637627 DOI: 10.1212/wnl.0000000000011750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/15/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate whether participating in physical contact sports is associated with a release of neurofilaments and whether such release is related to future clinical neurologic and/or psychiatric impairment. METHODS We performed a systematic review of the PubMed, MEDLINE, and Cochrane Library databases using a combination of the search terms neurofilament(s)/intermediate filament and sport(s)/athletes. Original studies, written in English, reporting on neurofilaments in CSF and/or serum/plasma of contact sport athletes were included. This review was conducted following the Preferred Reporting Items for Systematic Review and Analyses guidelines. RESULTS Eighteen studies in 8 different contact sports (i.e., boxing, American football, ice hockey, soccer, mixed martial arts, lacrosse, rugby, and wrestling) matched our criteria. Elevated light chain neurofilament (NfL) levels were described in 13/18 cohorts. Most compelling evidence was present in boxing and American football, where exposure-related increases were appreciable at the intraindividual level (up to 4.1- and 2.0-fold, respectively) in well-defined groups. Differences in exposure severity (including previous cumulative effects), sampling/measurement time points (with regard to expected peak values), and definitions of the baseline setting are considered as main contributors to the variability in findings. No studies were encountered that have investigated the relationship with the targeted clinical end points; therefore no NfL cutoffs exist that are associated with a poor outcome. CONCLUSION NfL release can be seen, as a potential marker of neuronal brain damage, in participants of physical contact sports, particularly boxing and American football. The exact significance regarding the risk for future clinical impairment remains to be elucidated.
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Affiliation(s)
- Carl Verduyn
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium.
| | - Maria Bjerke
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium
| | - Johnny Duerinck
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium
| | - Sebastiaan Engelborghs
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium
| | - Koenraad Peers
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium
| | - Jan Versijpt
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium
| | - Miguel D'haeseleer
- From the Department of Physical Medicine and Rehabilitation (C.V., K.P.), Universitair Ziekenhuis Leuven; Katholieke Universiteit Leuven; Center for Neurosciences (M.B., J.D., S.E., J.V., M.D.), Vrije Universiteit Brussel; Reference Center for Biological Markers of Dementia (M.B., S.E.), Institute Born-Bunge, Universiteit Antwerpen; Neurochemistry Laboratory (M.B.), Department of Clinical Biology, Universitair Ziekenhuis Brussel; Department of Neurosurgery (J.D.), Universitair Ziekenhuis Brussel; Department of Neurology (S.E., J.V., M.D.), Universitair Ziekenhuis Brussel; and Nationaal Multiple Sclerose Centrum (M.D.); Melsbroek, Belgium
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