Persistent effects of playing football and associated (subconcussive) head trauma on brain structure and function: a systematic review of the literature.
OBJECTIVE
There is ongoing controversy about persistent neurological deficits in active and former football (soccer) players. We reviewed the literature for associations between football activities (including heading/head injuries) and decline in brain structure/function.


METHODS
Systematic literature review.


METHODS
MEDLINE, Embase, PsycINFO, CINAHL, Cochrane-CRCT, SportDiscus, Cochrane-DSR=4 (accessed 2 August 2016).


METHODS
Original studies reporting on football-related persistent effects on brain structure/function. Results from neurocognitive testing, neuroimaging and EEG were compared with controls and/or correlated with heading frequency and/or head injuries. Methodological quality was rated for risk-of-bias, including appropriateness of controls, correction for multiple statistical testing and assessment of heading frequency and head injuries.


RESULTS
30 studies with 1691 players were included. Those 57% (8/14) of case-control studies reporting persistent neurocognitive impairment had higher odds for inappropriate control of type 1 errors (OR=17.35 (95% CI (10.61 to 28.36)) and for inappropriate selection of controls (OR=1.72 (1.22 to 2.43)) than studies observing no impairment. Studies reporting a correlation between heading frequency and neurocognitive deficits (6/17) had lower quality of heading assessment (OR=14.20 (9.01 to 22.39)) than studies reporting no such correlation. In 7 of 13 studies (54%), the number of head injuries correlated with the degree of neurocognitive impairment. Abnormalities on neuroimaging (6/8 studies) were associated with subclinical neurocognitive deficits in 3 of 4 studies.


CONCLUSIONS
Various methodological shortcomings limit the evidence for persistent effects of football play on brain structure/function. Sources of bias include low-quality assessment of heading frequency, inappropriate control for type 1 errors and inappropriate selection of controls. Combining neuroimaging techniques with neurocognitive testing in prospective studies seems most promising to further clarify on the impact of football on the brain.
Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland.|Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.
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http://orcid.org/0000-0002-6984-6958
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Tarnutzer
Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland.|Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.
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D
Straumann
Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
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Brugger
Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland.|Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.
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Feddermann-Demont
D001265:Athletic Injuries / Q000503:physiopathology*; D001921:Brain / Q000503:physiopathology*; D006259:Craniocerebral Trauma / Q000503:physiopathology*; D004569:Electroencephalography; D006801:Humans; D059906:Neuroimaging; D009483:Neuropsychological Tests; D012916:Soccer / Q000293:injuries*
Football; Neurology; Sporting injuries; Trauma