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- 19 July 2022

Brain Concussions in Sports and Chronic Traumatic Encephalopathy

Find out the possible adverse effects on the brain of concussions in Sports and what methods can be applied to prevent and reduce them.

Already in July 2019, Dr. Stefano Pallanti addressed the topic of brain injury in sports professionals in an article that took its cue from the tragic death of a top soccer player at Fiorentina football club. Following the recent confessions of two well-known international rugby players about the serious health problems they face at the end of their careers, this topic is extremely relevant. Picking up on part of a text originally published in our original magazine Firenze Neuroscienze, we will further explore this important issue.

Soccer: a risk factor for dementia?

A football champion from the Fiorentina soccer team passed away due to the consequences of an unusual neurological disorder characterized by severe cognitive impairment. This disease tormented him for 8 years, progressively depriving him of his cognitive and linguistic abilities.

In an attempt to explain the cause of this tragic death, some have noted similarities with a condition known as frontotemporal dementia, a disease similar to Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig's disease, the famous baseball player whose case drew public attention in 1939.

ALS ― also called Charcot's disease ― is a progressive neurodegenerative condition affecting motor neurons. One theory regarding the origin of this terrible disease suggests that abrasive contact with the playing field could be a risk factor, creating conditions favorable to the development of rare and slow-growing infectious forms, including cyanobacteria. In fact, during his baseball career, Lou Gehrig throughout his baseball career was often exposed to abrasions caused by the playing field, and it's hypothesized that this exposure may have facilitated the transmission of pathogenic microorganisms. Could this be the explanation behind the neurological disorder that led to the Fiorentina player's death? It's one of the hypotheses.

Other hypotheses, on the other hand, have pointed to the abuse of certain drugs allowed in the past but now banned as a possible cause of the Fiorentina champion's death. Still, others have suggested that extensive use of Roentgen rays for treating Pubalgia, a common disorder among soccer players, might be linked to the neurological disorder presented by the deceased player.

Despite the various proposed theories, there seems to be some reluctance to seriously consider the hypothesis linking soccer activity to frontotemporal dementia, a pathological condition often associated with repeated head traumas, such as those that can occur in contact sports. The scientific and sports communities should delve deeper into this issue to better understand the risks associated with soccer and implement appropriate preventive measures.

The connection between Head Trauma and Neurodegenerative Diseases.

Outside of Europe ― where Soccer does not represent an almost untouchable institution ― and especially in the United States, many studies have already extensively documented the connection between head traumas ― even mild but frequent ones ― and the development of neurodegenerative diseases like frontotemporal dementia.

For instance, there is now a wealth of scientific data supporting the correlation between professional American Football and long-term brain damage, a hypothesis increasingly confirmed by recent studies. Some may argue that "American football is an entirely different game, much more violent than Soccer." While this is certainly true, when it comes to head traumas, the differences may not be as significant.

Prominent researchers at Boston University examined 111 brains of former NFL (National Football League) players who had undergone "normal" head traumas, that is, without loss of consciousness or obvious concussions. From the data obtained from the analysis of these brains, it was revealed that 110 of them displayed signs of Chronic Traumatic Encephalopathy (CTE), a degenerative brain disease associated with repeated head impacts. Access the full article ➜

These types of traumas might be detectable during a person's lifetime, enabling early identification and the necessary preventive measures to avoid long-term damage. An effective method for identifying them could be Magnetic Resonance Imaging, but the use of a revealing protein called CLL11 has also been proposed as a possible marker for the presence of a degenerative process similar to premature brain aging.

Fortunately, even in Soccer, there is a growing awareness of the potential harm caused by head impacts, not only from direct ball hits but also from collisions with other players, often frequent in situations like corner kicks.

Brain Damage Caused by Headers

Results obtained in a study conducted at Purdue University revealed that soccer players who repeatedly hit the ball with their heads during matches or training sessions suffer damage to the small blood vessels that supply the brain, which require time and rest to regenerate.

Considering the frequency of matches that many soccer players undergo, this aspect should be taken seriously. It's also important to note that a soccer ball is not lightweight, and those who have experienced the impact of a header can confirm how challenging it can be. Researchers at Purdue University have highlighted that the impact generated by a ball kicked during a free-kick can be likened to that experienced in American football or a punch delivered in a boxing match.

The connection between Soccer and Chronic Traumatic Encephalopathy (CTE)

Some researchers at the University College London recently published the results of a groundbreaking study on CTE (Chronic Traumatic Encephalopathy), specifically in soccer, in the Acta Neuropathologica journal. Their examination of the brains of six professional soccer players revealed signs of Alzheimer's, with four of them also showing the typical accumulation of proteins associated with CTE. The lead author of the study, Helen Ling, emphasized in an interview: «This is the first time that CTE has been confirmed in a group of retired soccer players; our results suggest a potential link between playing soccer and the development of degenerative brain conditions in later life.»

These findings are further supported by another English study published in 2017, conducted on a group of 14 retired soccer players suffering from dementia, tracked through prospective observation until 1980. Following the death of some of these former players, post-mortem brain analyses revealed significant evidence of CTE in the majority of them.

Although the causes of the observed results are not yet clearly defined scientifically, the increasing number of similar cases raises legitimate concerns among players regarding the possible relationship between soccer and the onset of long-term brain diseases.

In the United States, where American football (notoriously more violent than soccer) is more prevalent, awareness of this phenomenon is higher. Families of professional American football players, concerned about the mental health of their loved ones, often donate their brains for research purposes. This has so far made it possible to analyze as many as 425 brains, 270 of which chronic traumatic encephalopathy has been diagnosed.

Similar extensive research on soccer unfortunately does not yet exist in the current literature. Nevertheless, many researchers believe that it is repeated and less violent headers, rather than more obvious traumatic brain injuries, that trigger CTE.

Cognitive Problems Caused by Headers

At the Albert Einstein College of Medicine, where Dr. Stefano Pallanti holds the position of Professor of Psychiatry, fellow neuroscientist Michael Lipton has identified what we might call the "trigger" in soccer. Lipton states, «In soccer, where players repeatedly hit the ball with their heads, the key question is, how many hits/traumas and how long does it take to cause pathology with an obvious clinical decline in cognitive function?». To answer this question, Lipton followed a group of about 400 amateur soccer players in New York, involving them in the "Einstein Soccer Study."

Initially, brain scans were conducted on the participants using Diffusion Tensor Imaging (a precise imaging modality that maps changes in the brain's white matter) and a specific blood test, followed by a series of tests aimed at measuring the cognitive abilities of the participants. The results of the study, published in the 'Neuroradiology' journal in 2013, revealed that even normal repeated headers, even in the absence of a concussion, are associated with cognitive problems and physical changes in the brain structure.

On average, soccer players head the ball 6 to 12 times per game. However, some players may execute dozens of headers per game, depending on their position or the style of play, perhaps trying to deflect balls traveling at speeds of up to 80 km/h, even in non-professional matches. The minor traumas resulting from repeated headers can accumulate. Lipton's study suggests that initial memory-related problems can start to emerge after approximately 1800 headers. Although this study systematically and comprehensively involved only 37 players, the results raise legitimate concerns.

Goals of future research

Unfortunately, as noted by Professor McKee of the CTE Center at Boston University, the only current method for diagnosing CTE is through a post-mortem brain autopsy. Nevertheless, there is ongoing exploration of the possibility of using a marker protein to test in the blood or urine, thus increasing the chances of diagnosing the disease during one's lifetime and being able to intervene early.


Training the brain for better performance: How neuroscience can improve sports performance

Sports and competitive performance represent a fertile area of investigation and intervention for the application of neuroscience.

At the Zucchi Wellness Clinic's Centro di Neuroscienze per la Salute, Dr. Stefano Pallanti and his team apply Neuromodulation Techniques to increase the brain's potential and facilitate the achievement of sports goals.

Key Actions for Prevention and Treatment

The opportunity for Dr. Stefano Pallanti to work at the Sports Psychiatry department at Stanford in collaboration with the San Francisco 49ers NFL players has allowed him to further emphasize his sensitivity to this problem. For this reason, he then began to consider the following question: What can we do about it?

  • DO NOT DENY THE PROBLEM: Denying the problem never constitutes a solution. Taking the issue seriously on a large scale would already be a significant step forward.

  • INFORM: One of the initial key actions is to inform all those involved in the sector, including players, managers, and medical professionals, about the risks associated not only with evident brain injuries but also with repeated headers.

  • PREVENT: It would also be appropriate to consider the idea of introducing specific helmets similar to those used in boxing for the protection of younger players who are entering the world of soccer.

  • MONITOR: Additionally, it is essential to monitor the brain's functioning not only through traditional imaging tests like CT scans or MRIs but also through neurophysiological tests, quantitative EEGs, diffusion tensor imaging, and vascular investigations. In conjunction with this, it would be important to monitor the attention capabilities of players, the trend of which over time could be correlated with the issue.

  • EARLY INTERVENTIONS: Equally important is the ability to intervene early for the rehabilitation of deteriorated cognitive functions, using techniques such as Photo-Bio-Modulation, Neurofeedback, and other methods capable of accelerating functional recovery and reducing long-term vascular damage.

To achieve these objectives, the Istituto di Neuroscienze has developed and established the Behavioral Health and Performance Service, to inform and empower individuals by providing them with valuable information for the protection of their own and their loved ones' health.

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