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CC BY-NC-ND 4.0 · Int J Sports Med 2025; 46(03): 151-163
DOI: 10.1055/a-2409-0323
Review

Cognitive Effects of Heading in Professional Football: A Systematic Review

Liam Patel
1   Institute of Sport Exercise and Health, UCL, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN4919)
,
Julikram Tarafder
1   Institute of Sport Exercise and Health, UCL, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN4919)
,
Flaminia Ronca 
1   Institute of Sport Exercise and Health, UCL, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN4919)
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Abstract

Large cohort studies have reported that former professional football players have an increased risk of mortality from neurodegenerative disease. Due to emerging concerns regarding the safety of heading the technique is now banned for players under 12. The aim of this systematic review was to evaluate the association between heading exposure and cognitive function in professional football players. A search strategy was devised and entered into seven electronic databases: MEDLINE, Embase, Web of Science, PsycINFO, CENTRAL, SportDiscus and PEDro. The search identified 563 records. After screening records and applying the eligibility criteria, nine cross-sectional studies (n=925) were included in the review, investigating 452 current and 473 former players (859 males, 66 females). Six studies (n=595) reported evidence for an association between heading and impaired cognitive function, while three studies (n=330) reported no association. Diverse cognitive domains were investigated, which might underline the disparity in these results. The association between heading and cognitive function in professional football appears likely but remains inconclusive. Methodological heterogeneity and variability in the presentation of results limits the conclusions drawn. Prospective longitudinal studies using standardised methods, and including females, are required to provide evidence to support or refute an association.

Keywords

executive function - memory - brain - sport - concussion - soccer

Supplementary Material



Publication History

Received: 18 June 2024

Accepted: 02 September 2024

Accepted Manuscript online:
03 September 2024

Article published online:
02 December 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 FIFA. FIFA Big Count 2006. Big Count: Comparison 2006–2000. FIFA Communications Division. Zurich, Switzerland. 2007
    PubMed
  • 2 FIFA. The Football Landscape. Vision Report. 2020–2023. 2021. Internet: https://publications.fifa.com/en/vision-report-2021/the-football-landscape/ Accessed: 10.04.23
    PubMed
  • 3 Rutherford A, Stephens R, Potter D. The neuropsychology of heading and head trauma in Association Football (soccer): A review. Neuropsychol Rev 2003; 13: 153-179
    CrossrefPubMedSearch in Google Scholar
  • 4 Spiotta AM, Bartsch AJ, Benzel EC. Heading in soccer: Dangerous play?. Neurosurg 2012; 70: 1-11
    CrossrefPubMedSearch in Google Scholar
  • 5 Tysvaer A, Storli O. Association football injuries to the brain. A preliminary report. Br J Sports Med 1981; 15: 163-166
    CrossrefPubMedSearch in Google Scholar
  • 6 Tierney GJ, Higgins B. The incidence and mechanism of heading in European professional football players over three seasons. Scand J Med Sci Sports 2021; 31: 875-883
    CrossrefPubMedSearch in Google Scholar
  • 7 McCunn R, Beaudouin F, Stewart K. et al. Heading in Football: Incidence, Biomechanical Characteristics and the Association with Acute Cognitive Function-A Three-Part Systematic Review. Sports Med 2021; 51: 2147-2163
    CrossrefPubMedSearch in Google Scholar
  • 8 Bruno D, Rutherford A. Cognitive ability in former professional football (soccer) players is associated with estimated heading frequency. J Neuropsychol 2022; 16: 434-443
    CrossrefPubMedSearch in Google Scholar
  • 9 Cassoudesalle H, Laborde B, Orhant E. et al. Video analysis of concussion mechanisms and immediate management in French menʼs professional football (soccer) from 2015 to 2019. Scand J Med Sci Sports 2021; 31: 465-472
    CrossrefPubMedSearch in Google Scholar
  • 10 Basinas I, McElvenny DM, Pearce N. et al. A Systematic Review of Head Impacts and Acceleration Associated with Soccer. Int J Environ Res Public Health 2022; 19: 5488
    CrossrefPubMedSearch in Google Scholar
  • 11 Kerr ZY, Marshall SW, Guskiewicz KM. Reliability of Concussion History in Former Professional Football Players. Med Sci Sports Exerc 2012; 44: 377-382
    CrossrefPubMedSearch in Google Scholar
  • 12 Ford JH, Giovanello KS, Guskiewicz KM. Episodic Memory in Former Professional Football Players with a History of Concussion: An Event-Related Functional Neuroimaging Study. J Neurotrauma 2013; 30: 1683-1701
    CrossrefPubMedSearch in Google Scholar
  • 13 Delaney JS, Lacroix VJ, Leclerc S. Concussions among university football and soccer players. Clin J Sport Med 2002; 12: 331-338
    CrossrefPubMedSearch in Google Scholar
  • 14 Prien A, Grafe A, Rössler R. et al. Epidemiology of Head Injuries Focusing on Concussions in Team Contact Sports: A Systematic Review. Sports Med 2018; 48: 953-969
    CrossrefPubMedSearch in Google Scholar
  • 15 Mainwaring L, Ferdinand Pennock KM, Mylabathula S. et al. Subconcussive head impacts in sport: A systematic review of the evidence. Int J Psychophysiol 2018; 132: 39-54
    CrossrefPubMedSearch in Google Scholar
  • 16 Hwang S, Ma L, Kawata K. et al. Vestibular dysfunction after subconcussive head impact. J Neurotrauma 2017; 34: 8-15
    CrossrefPubMedSearch in Google Scholar
  • 17 Bevilacqua ZW, Huibregtse ME, Kawata K. In Vivo Protocol of Controlled Subconcussive Head Impacts for the Validation of Field Study Data. J Vis Exp 2019; 18: 146
    PubMedSearch in Google Scholar
  • 18 Broglio SP, Eckner JT, Paulson HL. Cognitive decline and aging: the role of concussive and subconcussive impacts. Exerc Sport Sci Rev 2012; 40: 138-144
    CrossrefPubMedSearch in Google Scholar
  • 19 Yuan SH, Wang SG. Alzheimerʼs Dementia due to Suspected CTE from Subconcussive Head Impact. Case Rep Neurol Med 2018; 7890269
    PubMedSearch in Google Scholar
  • 20 Smirl JD, Peacock D, Burma JS. et al. An acute bout of controlled subconcussive impacts can alter dynamic cerebral autoregulation indices: A preliminary investigation. Eur J Appl Physiol 2022; 122: 1059-1070
    CrossrefPubMedSearch in Google Scholar
  • 21 Punnoose AR. Study raises concerns about “heading” in soccer, but jury is still out on risks. JAMA 2012; 307: 1012-1014
    CrossrefPubMedSearch in Google Scholar
  • 22 Bailes JE, Petraglia AL, Omalu BI. et al. Role of subconcussion in repetitive mild traumatic brain injury A review. J Neurosurg 2013; 119: 1235-1245
    CrossrefPubMedSearch in Google Scholar
  • 23 Mackay DF, Russell ER, Stewart K. et al. Neurodegenerative Disease Mortality among Former Professional Soccer Players. N Engl J Med 2019; 381: 1801-1808
    CrossrefPubMedSearch in Google Scholar
  • 24 Ueda P, Pasternak B, Lim CE. et al. Neurodegenerative disease among male elite football (soccer) players in Sweden: A cohort study. Lancet Public Health 2023; 8: e256-e265
    CrossrefPubMedSearch in Google Scholar
  • 25 Russell ER, Mackay DF, Stewart K. et al. Association of Field Position and Career Length With Risk of Neurodegenerative Disease in Male Former Professional Soccer Players. JAMA Neurol 2021; 78: 1057-1063
    CrossrefPubMedSearch in Google Scholar
  • 26 Snowden T, Reid H, Kennedy S. et al. Heading in the Right Direction: A Critical Review of Studies Examining the Effects of Heading in Soccer Players. J Neurotrauma 2021; 38: 169-188
    PubMedSearch in Google Scholar
  • 27 TheFA. English football introduces new guidance for heading ahead of 2021-22 season. 2021. Internet: https://www.londonfa.com/news/2021/jul/28/english-football-introduces-new-guidance-for-heading-ahead-of-2021-22-season Accessed 15.05.23
    PubMed
  • 28 TheFA. Updated heading guidance announced for youth training sessions. 2020. Internet: https://www.thefa.com/news/2020/feb/24/updated-heading-guidance-announcement-240220 Accessed: 15.05.23
    PubMed
  • 29 TheFA. The FA to trial the removal of heading in U12 matches and below in 2022-23 season. 2022. Internet: https://www.thefa.com/news/2022/jul/18/statement-heading-trial-u12-games-20221807 Accessed: 15.05.23
    PubMed
  • 30 TheFA. New rule introduced to phase out heading in youth football over next three seasons. 2024. Internet: https://www.thefa.com/news/2024/may/17/new-heading-rules-for-grassroots-football-youth-matches Accessed: 18.05.24
    PubMed
  • 31 Maher ME, Hutchison M, Cusimano M. et al. Concussions and heading in soccer: A review of the evidence of incidence, mechanisms, biomarkers and neurocognitive outcomes. Brain Inj 2014; 28: 271-285
    CrossrefPubMedSearch in Google Scholar
  • 32 Kontos AP, Braithwaite R, Chrisman SPD. et al. Systematic review and meta-analysis of the effects of football heading. Br J Sports Med 2017; 51: 1118-1124
    CrossrefPubMedSearch in Google Scholar
  • 33 Tarnutzer AA, Straumann D, Brugger P. et al. Persistent effects of playing football and associated (subconcussive) head trauma on brain structure and function: A systematic review of the literature. Br J Sports Med 2017; 51: 1592-1604
    CrossrefPubMedSearch in Google Scholar
  • 34 Beaudouin F, Gioftsidou A, Larsen MN. et al. The UEFA Heading Study: Heading incidence in childrenʼs and youthʼ football (soccer) in eight European countries. Scand J Med Sci Sports 2020; 30: 1506-1517
    CrossrefPubMedSearch in Google Scholar
  • 35 Harriss A, Johnson AM, Walton DM. Head impact magnitudes that occur from purposeful soccer heading depend on the game scenario and head impact location. Musculoskelet Sci Pract 2019; 40: 53-57
    CrossrefPubMedSearch in Google Scholar
  • 36 Sandmo SB, Andersen TE, Koerte IK. et al. Head impact exposure in youth football-Are current interventions hitting the target?. Scand J Med Sci Sports 2020; 30: 193-198
    CrossrefPubMedSearch in Google Scholar
  • 37 Langdon S, Goedhart E, Oosterlaan J. 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
    CrossrefPubMedSearch in Google Scholar
  • 38 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
    CrossrefPubMedSearch in Google Scholar
  • 39 Ardern CL, Buttner F, Andrade R. et al. Implementing the 27 PRISMA 2020 Statement items for systematic reviews in the sport and exercise medicine, musculoskeletal rehabilitation and sports science fields: The PERSiST (implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science) guidance. Br J Sports Med 2022; 56: 175-195
    CrossrefPubMedSearch in Google Scholar
  • 40 Patel L, Tarafder J, Ronca F. Cognitive effects of heading in professional football: A systematic review. PROSPERO 2023; CRD42023404209
    PubMed
  • 41 Moola SMZ, Tufanaru C, Aromataris E. et al. CHECKLIST FOR ANALYTICAL CROSS SECTIONAL STUDIES. JBI Manual for Evidence Synthesis. 2021
    PubMedSearch in Google Scholar
  • 42 Ma L-L, Wang Y-Y, Yang Z-H. et al. Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better?. Mil Med Res 2020; 7: 7
    CrossrefPubMedSearch in Google Scholar
  • 43 Koerte IK, Lin AP, Muehlmann M. et al. Altered Neurochemistry in Former Professional Soccer Players without a History of Concussion. J Neurotrauma 2015; 32: 1287-1293
    CrossrefPubMedSearch in Google Scholar
  • 44 Koerte IK, Mayinger M, Muehlmann M. et al. Cortical thinning in former professional soccer players. Brain Imaging Behav 2016; 10: 792-798
    CrossrefPubMedSearch in Google Scholar
  • 45 Downs DS, Abwender D. Neuropsychological impairment in soccer athletes. J Sports Med Phys Fitness 2002; 42: 103-107
    PubMedSearch in Google Scholar
  • 46 Espahbodi S, Hogervorst E, Macnab TMP. et al. Heading frequency and risk of cognitive impairment in retired male professional soccer players. JAMA Netw Open 2023 6. e2323822
    PubMedSearch in Google Scholar
  • 47 Matser JT, Kessels AG, Jordan BD. et al. Chronic traumatic brain injury in professional soccer players. Neurology 1998; 51: 791-796
    CrossrefPubMedSearch in Google Scholar
  • 48 Matser JT, Kessels AG, Lezak MD. A dose-response relation of headers and concussions with cognitive impairment in professional soccer players. J Clin Exp Neuropsychol 2001; 23: 770-774
    CrossrefPubMedSearch in Google Scholar
  • 49 Rodrigues AC, Lima MDM, de Souza LC. et al. No Evidence of Association Between Soccer Heading and Cognitive Performance in Professional Soccer Players: Cross-Sectional Results. Front Neurol 2019; 10: 209
    CrossrefPubMedSearch in Google Scholar
  • 50 Straume-Naesheim TM, Andersen TE, Dvorak J. Effects of heading exposure and previous concussions on neuropsychological performance among Norwegian elite footballers. Brit J Sports Med 2005; 39: i70-i77
    CrossrefPubMedSearch in Google Scholar
  • 51 Prien A, Feddermann-Demont N, Verhagen E. et al. Neurocognitive performance and mental health of retired female football players compared to non-contact sport athletes. BMJ Open Sport Exerc Med 2020; 6: e000952
    CrossrefPubMedSearch in Google Scholar
  • 52 American Psychiatric A. Diagnostic and statistical manual of mental disorders: DSM-5-TR: Hardcover. 5th ed. American Psychiatric Association; 2022
    CrossrefSearch in Google Scholar
  • 53 Snow PJ. The Structural and Functional Organization of Cognition. Front Hum Neurosci 2016; 10: 501
    PubMedSearch in Google Scholar
  • 54 Russell E. Toward an Explanation of Dodrills Observation: High Neuropsychological Test Performance Does not Accompany High IQs. Clin Neuropsychol 2001; 15: 423-428
    CrossrefPubMedSearch in Google Scholar
  • 55 Gaudet CE, Konin J, Faust D. Immediate Post-concussion and Cognitive Testing: Ceiling Effects, Reliability, and Implications for Interpretation. Arch Clin Neuropsychol 2020; 36: 561-569
    CrossrefPubMedSearch in Google Scholar
  • 56 Tong T, Chignell M, DeGuzman CA. Using a serious game to measure executive functioning: Response inhibition ability. Appl Neuropsychol Adult 2021; 28: 673-684
    CrossrefPubMedSearch in Google Scholar
  • 57 Rubin TG, Catenaccio E, Fleysher R. et al. MRI-defined White Matter Microstructural Alteration Associated with Soccer Heading Is More Extensive in Women than Men. Radiology 2018; 289: 478-486
    CrossrefPubMedSearch in Google Scholar
  • 58 Jordan SE, Green GA, Galanty HL. et al. Acute and chronic brain injury in United States national team soccer players. / Traumatisme cerebral aigu et chronique chez les joueurs de football de lʼ equipe nationale des Etats-Unis. Amer. J Sports Med 1996; 24: 205-210
    CrossrefPubMedSearch in Google Scholar
  • 59 Vann Jones SA, Breakey RW, Evans PJ. Heading in football, long-term cognitive decline and dementia: Evidence from screening retired professional footballers. Br J Sports Med 2014; 48: 159-161
    CrossrefPubMedSearch in Google Scholar
  • 60 FIFA. Women’s Football Strategy. 2021. Internet: https://inside.fifa.com/womens-football/strategy/strategy-details Accessed 15.05.23
    PubMed
  • 61 Covassin T, Swanik CB, Sachs ML. Sex Differences and the Incidence of Concussions Among Collegiate Athletes. J Athl Train 2003; 38: 238-244
    PubMedSearch in Google Scholar
  • 62 Gessel LM, Fields SK, Collins CL. et al. Concussions among United States high school and collegiate athletes. J Athl Train 2007; 42: 495-503
    PubMedSearch in Google Scholar
  • 63 Rutherford A, Fernie G. The accuracy of footballersʼ frequency estimates of their own football heading. Appl Cogn Psych 2005; 19: 477-487
    CrossrefPubMedSearch in Google Scholar
  • 64 Sandmo SB, Gooijers J, Seer C. et al. Evaluating the validity of self-report as a method for quantifying heading exposure in male youth soccer. Res Sports Med 2021; 29: 427-439
    CrossrefPubMedSearch in Google Scholar
  • 65 Agot K, Taylor D, Corneli AL. et al. Accuracy of Self-Report and Pill-Count Measures of Adherence in the FEM-PrEP Clinical Trial: Implications for Future HIV-Prevention Trials. AIDS Behav 2015; 19: 743-751
    CrossrefPubMedSearch in Google Scholar
  • 66 Seijo M, Minckas N, Cormick G. et al. Comparison of self-reported and directly measured weight and height among women of reproductive age: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2018; 97: 429-439
    CrossrefPubMedSearch in Google Scholar
  • 67 Ozoh OB, Dania MG, Irusen EM. The Prevalence of Self-Reported Smoking and Validation with Urinary Cotinine Among Commercial Drivers in Major Parks in Lagos, Nigeria. J Public Health Afr 2014; 5: 316
    PubMedSearch in Google Scholar