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December 31
Neuroscience Ph.D. ************************** Passionate about science education and outreach; enjoys a great discussion about the intersection of science and everyday life *************************** Currently a biomedical researcher at a Harvard University hospital - Areas of expertise: endocrinology, appetite and metabolism, neuroscience, biochemistry, molecular biology *************************** Areas of interest: science and art, science and society, science policy, books/films/music, reading great magazines, travel, learning new things and sparking new ideas, gardening/nature *** All Content Copyright Aliquot - do not reproduce without express permission ***

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FEBRUARY 5, 2010 1:29PM

Dementia pugilistica: football's dirty little secret

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Can’t remember which football teams you’ve played for?  Forget who you defeated in that boxing ring?  Dementia pugilistica may be to blame.   Also known as Boxer’s syndrome, this type of Alzheimer’s Disease-like dementia is caused by repeated head trauma – like that experienced by boxers and football players.  And apparently, dementia pugilistica could also be a risk of dogfighting, too.  The image above (from shows brains injured from repeated head trauma.


While neurologists and neuroscientists have been aware of this form of dementia for decades, only recently has the topic hit the mainstream press.  Malcolm Gladwell’s piece for the New Yorker in October 2009 exposing the striking similarity between dog fighting and football  has been listed as one of the best articles of the year.  And just today, the New York Times is running an Op-Ed piece publicizing (concurrent with the run-up to the Superbowl and congressional hearings on football-related concussions) of all things, an article from the Journal of the American Medical Association (JAMA) from 1928.  In part, it warns:


“There is a very definite brain injury due to single or repeated blows on the head or jaw which cause multiple concussion hemorrhages. ... The condition can no longer be ignored by the medical profession or the public.”


While Alzheimer’s type dementia can only be definitively diagnosed by post-mortem examination of the brain, and staining for trademark beta-amyloid plaques and tau-containing neurofibrillary tangles, Alzheimer’s and other forms of dementia may exhibit similar symptoms in terms of patient behavior and memory loss.    Gladwell writes of a patient in an Alzheimer’s ward, whose brain was found post-mortem to lack beta-amyloid markers, but was chock-full of tau – suggesting chronic traumatic encephalopathy (C.T.E.), or a condition that progresses into dementia pugilistica.  An excerpt:


The stained tissue of Alzheimer’s patients typically shows the two trademarks of the disease—distinctive patterns of the proteins beta-amyloid and tau. Beta-amyloid is thought to lay the groundwork for dementia. Tau marks the critical second stage of the disease: it’s the protein that steadily builds up in brain cells, shutting them down and ultimately killing them. An immunostain of an Alzheimer’s patient looks, under the microscope, as if the tissue had been hit with a shotgun blast: the red and brown marks, corresponding to amyloid and tau, dot the entire surface. But this patient’s brain was different. There was damage only to specific surface regions of his brain, and the stains for amyloid came back negative. “This was all tau,” Ann McKee, who runs the hospital’s neuropathology laboratory, said. “There was not even a whiff of amyloid. And it was the most extraordinary damage. It was one of those cases that really took you aback.” The patient may have been in an Alzheimer’s facility, and may have looked and acted as if he had Alzheimer’s. But McKee realized that he had a different condition, called chronic traumatic encephalopathy (C.T.E.), which is a progressive neurological disorder found in people who have suffered some kind of brain trauma. C.T.E. has many of the same manifestations as Alzheimer’s: it begins with behavioral and personality changes, followed by disinhibition and irritability, before moving on to dementia. And C.T.E. appears later in life as well, because it takes a long time for the initial trauma to give rise to nerve-cell breakdown and death. But C.T.E. isn’t the result of an endogenous disease. It’s the result of injury. The patient, it turned out, had been a boxer in his youth. He had suffered from dementia for fifteen years because, decades earlier, he’d been hit too many times in the head.


Gladwell also writes that the rates of dementia pugilistica or C.T.E. in boxers and football players are strikingly high, especially when compared to a general population at old age:


“A long time ago, someone suggested that the [C.T.E. rate] in boxers was twenty per cent,” McKee told me. “I think it’s probably higher than that among boxers, and I also suspect that it’s going to end up being higher than that among football players as well. Why? Because every brain I’ve seen has this. To get this number in a sample this small is really unusual, and the findings are so far out of the norm. I only can say that because I have looked at thousands of brains for a long time. This isn’t something that you just see. I did the same exact thing for all the individuals from the Framingham heart study. We study them until they die. I run these exact same proteins, make these same slides—and we never see this.”


Many professional boxers, most famous of whom is probably Muhammed Ali, have been diagnosed with dementia pugilistica.  Recent research has also revealed that football players are also at a higher risk of dementia due to repeated head injury.  And sadly, the third example may now come from the world of dog fighting.  In dog fighting, the dogs are chosen for their ability to persevere – to keep charging at their opposition even when they’re injured.  And surely, risking brain damage at the same time, just like their human counterparts.


Nearly 100 years after the JAMA warning about head injuries, its about time we face facts about the risks of our spectator sports.


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I wrote a post on the same general topic. no more excuse for football.
I obviously agree.
Thanks for linking your post, Nick. Glad that this topic is getting multiple mentions on OS - v. important!
"From error to error, one discovers the truth."
I worry not about the NFL players (though I do). NFL players are adults. What worries me most are the legions of middle school and high school players. Playing for the glory of their schools, under those confounded Friday Night Lights.

I grew up in a small town, where the whole town turned up for the week's game. In high school, I played in the band. I have fond memories of the community, the cheering, the ritual.

But at what price?
Thank you for this, Aliquot. xox
There's to much money involved to look at it accurately. And the networks are no help. LIke politics or corrupt business, ad revenue mean silence. Of course getting hit in the head repeadedly causes health risks. Blunt trauma to the head over years can't be good.
I think the important thing is that football, as it is currently played, is now similar to dog fighting. It is inherently dangerous and brain damage is now known to be the result of repetitive trauma and not an accident.

I suppose that it is reasonable to assume that adults can be considered able to assume the risk of partaking in an inherently dangerous activity. However, the morality of allowing minors to participate in football is something that will look worse and worse over time.

Just say no to a brutal game.
I guess we all could just live in a bubble,and never risk any thing in life.
Baseball is out also because you could get hit in the head.
Don't even think about getting on a motor cycle.

Let's face life carries risk.
Some times you have to risk life to live life.

Just my opinon
Very interesting. I wonder how Ali's dementia pugilistica can be distinguished from the dementia of late Parkinson's. Great piece.
Yay, Aliquot. Great job. I agree with Froggy's concerns, about young people who get repeated head trauma from contact sports, even to the point of concussions, who are allowed and even encouraged to return to play soon after recovering.
I saw an interview with John Mackey's(former tight end with the Baltimmore Colts) wife awhile back and he was sitting next to her. She was explaining his condition because he had no clue what was going on around him. It was sad.

The NFL has FINALLY taken steps regarding concussions and will work with the players and doctors much more than they have in the past.
Thanks for all the great comments!

Froggy - I agree that age is certainly a factor, especially if young folks are still developing when they receive repeated head trauma...and plus, there appears to be an additive effect so if you play in high school, then college, then pro...well, you get the idea.

Snoreville, I think you're right that profit (for teams, networks, etc) is certainly a reason that this is still a newsmaking topic so many years after the 1928 JAMA article...but am glad to see ESPN and congress are giving it the attention it deserves this superbowl season. I'm sure we'll never see dangerous sports disappear, but perhaps preventive measures can be taken to help with brain (and overall) health.

incandescent - funny! Its true, we must beware of correlation vs causation!

buds...of course life carries risk, but I think motorcycles and baseball are inherently different because there is not repeated head trauma, which appears to be the problem for football, boxing and dog fighting (thanks for bringing the dogs back into this with your second comment, Nick).

Good question, Steve! Parkinsons tremors are probably distinguishable from dementia's behavioral/memory manifestations, but there are certainly many overlaps between symptoms of the two conditions (as you MDs know!).

Thanks for your kind comments, Linda and Robin!

Blackflon - thanks for this anecdote, sad indeed! So many families are likely affected by dementia pugilistica.
Hi aliquot

A few other points about the religion of football. Football is an oddball in that most all other sports that kids play in childhood/teenagerhood, they can play the rest of their lives. Basketball, soccer, swimming, track, softball, golf, tennis, volleyball, etc. Parks and recreation departments across the country are full of adult versions of these sports.

Not football. It's too expensive, too dangerous, and too injury prone for anyone to play for fun on the weekends.

Football is also an oddball in that because of this effect (no playing outside highly organized leagues) the numbers of players diminish over time. Youth football is typically open to all comers, to any kid who wants to pay the money and bash their heads up week after week. But by high school, only so many kids make the high school team, and the rest drop out. Same with college, then into the NFL.

If you think about the average NFL player who may have been having repeated head trauma since MIDDLE SCHOOL, it's enough to make you crazy. Head trauma, every day, for months out of the year, from the age of 11, to, say, 35?


(Glad my kid has never wanted to play football.)

(I'm really beginning to wonder about the sanity of the families of my acquaintance who let their middle-school age boys play football. After years and years of bike helmets, car seats, ski helmets, and not letting them play in the street.)
It's not just football concussions, it's any concussion. They add up over the years.
Excellent post, and very important. I do worry about the high school football players... high school football is a very big deal in my small town. I worry also about boxers suffering from this sport-induced damage. Kind of Blue wrote a post awhile back about the amazing Muhammad Ali, who sadly is/may be a victim of this damage. I love to watch boxing and football, but I don't want anyone to be permanently damaged in the pursuit of those sports. Boxers and football players, you have your warning(s).
However, I do know for a fact that obsessively watching hockey games on TV definitely does lead to brain damage. Just ask my husband, if he's in any condition to reply to the question. (And for heaven's sake, don't ask him during a game!)
Froggy - thanks for the additional comments, and great points! Everytime a helmet hit something with a thud during the superbowl last night, I shuddered as well!

Poppi - indeed, you're correct. Its just that football players and boxers are more likely to experience a high number of concussions and head traumas over a lifetime.

ZaZaCat - thanks for your comments. Interesting point about hockey - which can be a quite violent, too! I don't think head injuries are as prevalent on the ice rink, though...
I think you're right on with this: we may enjoy these sports, but as spectators, we don't want people being seriously injured in the pursuit of our entertainment!
I remember seing my first patient with pugilism. I was a medical student doing a rotation in Medicine at Mt Sinai. An older man was admitted who was a Golden Glove Boxer in the 40s and according to his family " got beat up a number of times" While he was 70 and quite demented the family told me he could not even hold a job since his mid 50s. Now we hear that no one was watching what was going on in the NFL , or for that matter the AFL. Shame!
Superb! Thank you for this fantastic post.
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