Cited by 446Traumatic Brain Injury ResearchSports injuries and preventionPhysical Activity and Health

The DOI matches its Crossref record; 205 of the 205 references it cites were found in a registry or an index; 7 of the 218 sources its claims cite were checked for support.

The neuropathology of sport

Open access

Abstract

The benefits of regular exercise, physical fitness and sports participation on cardiovascular and brain health are undeniable. Physical activity reduces the risk for cardiovascular disease, type 2 diabetes, hypertension, obesity, and stroke, and produces beneficial effects on cholesterol levels, antioxidant systems, inflammation, and vascular function. Exercise also enhances psychological health, reduces age-related loss of brain volume, improves cognition, reduces the risk of developing dementia, and impedes neurodegeneration. Nonetheless, the play of sports is associated with risks, including a risk for mild TBI (mTBI) and, rarely, catastrophic traumatic injury and death. There is also growing awareness that repetitive mTBIs, such as concussion and subconcussion, can occasionally produce persistent cognitive, behavioral, and psychiatric problems as well as lead to the development of a neurodegeneration, chronic traumatic encephalopathy (CTE). In this review, we summarize the beneficial aspects of sports participation on psychological, emotional, physical and cognitive health, and specifically analyze some of the less common adverse neuropathological outcomes, including concussion, second-impact syndrome, juvenile head trauma syndrome, catastrophic sudden death, and CTE. CTE is a latent neurodegeneration clinically associated with behavioral changes, executive dysfunction and cognitive impairments, and pathologically characterized by frontal and temporal lobe atrophy, neuronal and axonal loss, and abnormal deposits of paired helical filament (PHF)-tau and 43 kDa TAR deoxyribonucleic acid (DNA)-binding protein (TDP-43). CTE often occurs as a sole diagnosis, but may be associated with other neurodegenerative disorders, including motor neuron disease (CTE-MND). Although the incidence and prevalence of CTE are not known, CTE has been reported most frequently in American football players and boxers. Other sports associated with CTE include ice hockey, professional wrestling, soccer, rugby, and baseball.

Overview

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Written from the paper’s full text.

TL;DR

This review summarizes both the health benefits of exercise and sports participation and the adverse neuropathological outcomes, especially concussion and chronic traumatic encephalopathy (CTE). It reports that repetitive mild TBI in sport can produce persistent symptoms and, in some athletes, CTE, while emphasizing that CTE incidence and prevalence remain unknown.

Key findings

  • Exercise and sports participation reduce risk for cardiovascular disease, type 2 diabetes, hypertension, obesity, and stroke; increased baseline physical activity reduces dementia risk by 28% and Alzheimer’s disease risk by 45%, and midlife moderate activity is associated with a 39% lower risk of mild cognitive impairment.
  • The CDC estimates 1.6–3.8 million sports/recreational concussions annually in the US, with 10–30% developing prolonged symptoms. High school football concussion rates were 0.21 per 1,000 athlete-exposures (A-E) in practice and 1.55 per 1,000 A-E in competition, versus 0.39 and 3.02 in collegiate football; soccer rates ranged from 1.38 per 1,000 game-time A-E for boys to 1.80 for girls; rugby mTBI incidence was 7.97 per 1,000 player game hours, with 313 of 3,207 players (9.8%) sustaining ≥1 mTBI and headgear associated with reduced risk (incident rate ratio 0.57).
  • In the mTBI brain bank, 117 athlete brains were analyzed (115M:2F; age 14–98 years, mean 54.1), including 6 athletes who died within 6 months of a reported concussion. Among 103 neuropathologically confirmed CTE cases, co-existent Lewy body disease was found in 12%, motor neuron disease in 13%, Alzheimer’s disease in 15%, and frontotemporal lobar degeneration in 6%.
  • CTE showed two clinical presentations: behavioral/mood symptoms with mean onset at 35 years and cognitive impairment with mean onset at 59 years; 86% of the behavioral/mood group progressed to cognitive symptoms, while 46% of the cognitive group developed behavioral/mood disorders. Pathologically, CTE is staged I–IV by PHF-tau topography; in the autopsy series, 33% of NFL players with Stage II or III CTE died by suicide, and suicide combined with drug or alcohol abuse accounted for 55% of deaths, while no Stage IV athletes died from suicide or drug overdose.

Methods

  • Design: narrative review of the beneficial effects of sports/exercise and the less common adverse neuropathological outcomes, including concussion, second-impact syndrome, juvenile head trauma syndrome, catastrophic sudden death, and CTE.
  • Data/sample: synthesis of published literature plus neuropathological case material from the mTBI brain bank at VA Boston/Boston University School of Medicine, including 117 athlete brains and a current experience of 103 neuropathologically confirmed CTE cases.
  • Main analysis: descriptive synthesis; CTE cases were classified into Stages I–IV based on the topography of phosphorylated tau pathology, with additional assessment of TDP-43 pathology and axonal injury. No systematic search strategy or meta-analysis is described.

Limitations

  • The paper states that the incidence and prevalence of CTE are not known and that precise determination will require longitudinal clinical studies and the ability to diagnose CTE during life.
  • The paper states that the definition of second-impact syndrome is controversial and some investigators have challenged its existence; the relationship of second-impact syndrome to juvenile head trauma syndrome is uncertain; and CTE diagnostic and staging criteria are provisional, with formal consensus validation in progress.
  • Evident from the text: this is a narrative review without a described systematic search; the autopsy series is subject to selection/referral bias from brain donation; and some cited clinical/epidemiological data rely on self-reported concussions or lack neuropathological verification (e.g., death certificates indicating AD or ALS in retired NFL players).

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Integrity signals

Registry

Crossref · 10.1007/s00401-013-1230-6

Cites

205 of 205 references verified0 citation errors · 0 not checkable

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Verification

Claims the paper makes

111 Not checked yet · 14 Own interpretation · 14 No basis given · 13 Own result · 2 Partly supported · 1 Mixed support · accuracy not yet measured

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  • It may state two separate claims as one. 81
  • The quote only partly states this claim. 1
  • Probably not a substantial claim. 11
89 of 89
  • The paper relies on this without support.

    The 117 athletes in the mTBI brain bank are representative of athletes who sustain concussions, so neuropathological findings in them can be generalized to concussion pathology in athletes.

    “Over the last 5 years, 117 brains of athletes, defined as a player over the age of 12 years who participated in organized sports for at least 3 consecutive years, have been analyzed at the mTBI brain bank at VA Boston/Boston University School of Medicine.”
  • The paper relies on this without support.

    Self-reported concussion history in retired players accurately reflects exposure to repetitive brain trauma.

    “surveys of retired professional football players found that players who reported sustaining three or more concussions were significantly more likely to report cognitive symptoms, including a threefold increase in self-reported significant memory impairment and a fivefold increase in diagnosed mild cognitive impairment [77].”
  • The paper relies on this without support.

    The provisional pathological diagnostic criteria and four-stage staging system for CTE are valid for classifying the cases described.

    “Provisional criteria for the pathological diagnosis of CTE and four pathological stages of severity have been proposed based on the topography of PHF-tau pathology [128]; formal consensus validation of these diagnostic and staging criteria by a large group of neuropathologists is currently in progress”
  • The paper relies on this without support.

    The autopsy series of neuropathologically confirmed CTE cases is representative enough to estimate co-occurrence, clinical features, and mortality patterns.

    “In our current experience of 103 neuropathologically confirmed cases of CTE, co-existent LBD was found in 12 (12 %) cases, MND in 13 (13 %), AD in 15 (15 %), and FTLD in 6 (6 %)”
  • The paper relies on this without support.

    The clinical symptoms reported in subjects with each CTE stage are attributable to the CTE pathology rather than to other causes.

    “Symptoms in Stage II CTE are variable, but in some instances there are prominent behavioral and personality changes, paranoia, irritability, depression, headaches, and short-term memory loss.”
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Metadata

Authors
McKee, A. C., Daneshvar, D. H., Alvarez, V. E., & Stein, T. D.
Affiliations
  • VA Boston Healthcare System (US)
  • Boston University (US)
Corresponding author
McKee, Ann C.
Venue
Acta Neuropathologica
Published
2013-12-24
Volume
127
Issue
1
Pages
29-51
ISSN
  • 0001-6322 (ISSN-L)
  • 1432-0533
OpenAlex
W2162142017
Cited by
422
References
205
Citations by year
2026: 12 · 2025: 23 · 2024: 29 · 2023: 38 · 2022: 40 · 2021: 32 · 2020: 32 · 2019: 40 · 2018: 33 · 2017: 40 · 2016: 36 · 2015: 53 · 2014: 13
FWCI
4.03
Type
journal article
Language
en
Open access
Locations
  • Acta Neuropathologica (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • U.S. Department of Veterans Affairs (I01 CX001038)
  • U.S. Public Health Service (0572063345-5)
  • National Institute on Aging (R01AG1649, P30AG013846, P30-AG13846))
  • National Institute of Neurological Disorders and Stroke (U01NS086659)
Topics
  • Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports injuries and prevention
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
Keywords
chronic traumatic encephalopathy, concussion, mild traumatic brain injury, second impact syndrome, neurodegeneration, TDP-43, sports-related brain injury, cognitive impairment, executive dysfunction, American football, boxing
MeSH terms
Animals, Athletic Injuries, Brain, Brain Injuries, Cognition, Humans, Sports

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