**3. What about other famous sportsmen?**

Hall of Fame in 2007. Near the end of 2008, Van der Westhuizen first noticed weakness in his right arm. A few months later, he was play-fighting in a swimming pool with a friend who was also his personal doctor, and discovered further weakness in the arm, a diagnosis of ALS was confirmed in 2011. Modified from: http://www.eurosport.com/rugby/van-derwesthuizen-sees-a-link\_sto4476535/story.shtml. **Jarrod Cunningham** (7 September 1968-22 July 2007) was a New Zealand rugby union fullback, who died from ALS. After tests at Charing Cross Hospital, Cunningham was diagnosed with ALS in June 2002. He immedi‐ ately retired from professional rugby, and started the Jarrod Cunningham SALSA Founda‐ tion in March 2003 with the aim of providing hope, education and inspiration for fellow sufferers of ALS. He returned home to New Zealand in December 2004 and died at his home on 22 July 2007. **Herbert Krug** (21 June 1937-1 November 2010) was a German eques‐ trian who won a gold medal in team dressage at the 1984 Summer Olympics in Los Angeles. He was born in Mainz and died in Hochheim am Main due to ALS. **Krzysztof Nowak** (27 September 1975-26 May 2005) was a Polish football player, best known for his stint with the VfL Wolfsburg team. He was forced to retire from the sport in early 2002 after he learned he had ALS. **Donald George "Don" Revie** was an England international footballer. In the spring of 1986, Revie moved to Kinross, Scotland where he intended to retire, but he was diagnosed with motor neurone disease in May 1987. Revie publicly announced his illness in August of that year, and made his final public appearance on 11 May 1988 at Elland Road in a wheelchair. He died in Murrayfield Hospital in Edinburgh on 26 May 1989, aged 61. Mar‐ thinus 'Tinus' Linee (see **Figure 3**) played rugby predominantly at the centre. In April 2013, Linee was diagnosed with motor neurone disease. His deteriorating health resulted in him having financial difficulties in an attempt to cover his medical costs. Linee died on 3 No‐

**John Mudgeway** was born in Masterton, he attended school in New Zealand, was an active rower and was in the school's rugby union first XV. He was diagnosed with motor neurone disease in 2002. **Ryan Walker** was born on 5 October 1978 in Pietermaritzburg (South Africa) and grew up on a beef and dairy farm in Mooi River. He was admitted in hospital for 5 days and had extensive blood tests, nerve tests, MRI and lumbar punctures. All the results came back clear. Ryan then went for his follow-up appointment with his attending doctor 4 weeks later who told him that he had ALS, and that there was no treatment available and that the prognosis was 2-5 years. More biographic information about all mentioned athletes is available

Due to the large number of rugby players affected by ALS in South Africa, many people have questioned whether there is a link between rugby-linked head injuries and motor neuron disease in light of cases including those of Joost van der Westhuizen, Tinus Linee, John Mudgeway, Ryan Walker and Jarrod Cunningham, all professional South African rugby players who suffered from the disease [49, 53]. Due to the increasing report of sportsmen presenting ALS, of all the putative risk factors, head injury has emerged as a strong cause for

At the present moment, there are more available facilities for confirmation of ALS, the disease is better known and the remarkable progress reached by the media and Internet has made their

vember 2014, aged 45 in his family home in Paarl, South Africa.

initiating the neurodegenerative processes in ALS patients [38, 39].

at the URL: https://en.wikipedia.org.

8 Update on Amyotrophic Lateral Sclerosis

Looking for clinical features of ALS in other sportsmen, we reviewed the biography of 100 famous sporting personalities, including Pele, Muhammad Ali, Diego Armando Maradona and Manny Pacquiao, among others (more information is available at the URL: http:// www.biographyonline.net/sport/100-sporting-personalities.html), and it was a great sense of delight to find nobody was affected by ALS. Nevertheless, we also included other famous sporting personalities such as Lance Armstrong, Paula Radcliffe, Jose Mourinho, Henry Cooper, Stirling Moss, Wayne Rooney, Bill Shankly and Alex Ferguson (more information is available at the URL: http://www.biographyonline.net/sport/100-sporting-personalities.html) and we also found that nobody presented clinical manifestations of ALS.

According to the results from the study made by Turner et al., it seems that more cases than expected of ALS are associated with a prior diagnosis of asthma, celiac disease, younger-onset diabetes (younger than 30 years), multiple sclerosis, myasthenia gravis, myxedema, polymyo‐ sitis, Sjögren syndrome, systemic lupus erythematosus and ulcerative colitis were confirmed, concluding that ALS raise the possibility of shared genetic or environmental risk factors [55]. These findings encouraged us to look into more groups of famous peoples to continue looking for the co-existence of ALS and other diseases. Then, we finally decided to review the biogra‐ phy of top 100 famous people, looking for the presence of ALS. That list of peoples was chosen mainly from the nineteenth, twentieth or twenty-first century and included famous actors, politicians, entrepreneurs, writers, artists and humanitarians (http://www.enkivillage.com/ most-famous-person-in-the-world.html). From this final review, we found that only two top famous people presented ALS: Mao Tse-tung and Stephen William Hawking.

From that observation, one single question came to our mind: What is different in those particular patients?

Mao was a Chairman of China. Some authors reported that out of the billions of people in China, Mao was the only person to ever have ALS, up to that time and also the authors asked: What did he do that none of the other Chinese did? In some authors' opinion Mao had a Western diet, meaning that he did not eat rice and vegetables; instead, he ate lots of meat and they considered that this type of diet (similar to Lou Gehrig's diet) may be part of the mechanism for ALS. More information is available at the URL: http://la.indymedia.org/news/ 2014/08/265540.php, http://www.scientificamerican.com/article/seeds-of-dementia-what-alz‐ hiemers-lou-gehrigs-parkinsons-have-in-common/. Despite this coincidence, we agree that this type of diet could be a contributing factor for ALS in a predisposed patient but without doubt, it is not the direct cause of the disease.

Stephen William Hawking also has some differences compared with the rest of the patients: Why has Hawking lived for more than 50 years with ALS when so many people die 1-5 years after diagnosis? Why he remains stable? We really do not know. Of course, Hawking has a variable of SALS; probably we got a late presentation of juvenile-onset disorder, which may progress very slowly. None has survived with ALS for so long as he did, providing a big hope for patients presenting ALS. Some authors think that it is a small percentage of people for whom that actually happens [56], and we do agree.

We concluded that no famous female presenting ALS has been reported ever. Apart from Mao Tse-tung and Stephen William Hawking, no other top famous people affected by ALS have been reported and both have some differences compared with the rest of the patients. In our opinion, the prognosis of ALS is bad, especially when there are bulbar and respiratory complications but not all patients have a progressive and invariably rapid fatal outcome, as has been found.
