Fistic Medicine: Dementia Pugilistica & MMA

By Matt Pitt Feb 13, 2010
I object to violence because when it appears to do good, the good is only temporary; the evil it does is permanent. - Mahatma Gandhi

It is rare to hear an athletic commission refer to criminality, particularly in respect to their own actions. But the case of Terry Norris was inescapable, even to Nevada State Athletic Commission Chairman Dr. Elias Ghanem.

"We will be really criminal if we let that happen the way he is now," Ghanem said, referring to Norris' appeal to have his boxing license reinstated.

Norris was a skilled lightweight boxer with fast hands and knockout power. He had a brilliant amateur career (291-4) before moving on to a 47-9 professional career and several years as champion. In February 2000, attempting a comeback, Norris appealed to the NSAC for reinstatement of his license. After witnessing Norris' slurred speech at the hearing, and comparing it to tapes of intact speech from only a few years prior, the request was unanimously denied.

Norris's camp explained the slurred speech was due to "lazy speech syndrome" -- a condition unknown to medicine. The commission, voiced by its vice chairman, disagreed: "We believe there is evidence of chronic brain injury. He should not fight again.”

Terry Norris was 33 years old -- a young but not atypical victim of Dementia Pugilistica.

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For well over a century, people involved in the world of fight sport have known that old age is harsh on fighters. In the 1920s a landmark paper was published detailing a syndrome of crippling senility in former fighters -- Dementia Pugilistica. At that time the prevalence of the disease was found to be approximately 20 percent of professional fighters. In the ensuing 100 years little changed: Today the rate of Dementia Pugilistica is still approximately 20 percent, and science has no idea what makes some fighters susceptible and others resistant.

Dementia Pugilistica, also known as Boxers' Dementia or Punch Drunk Syndrome, develops gradually and is irreversible. The early signs are subtle: changes in personality, impaired judgment, confusion, discrete deficits in memory. Over time the psychiatric complications become more profound--paranoia, impulsivity, aggression, depression, and ultimately functional dementia. Neuromotor dysfunction coincides with the psychiatric decline. Sufferers endure slurred speech, tremors, gait disturbance and gradually decline into immobility.

Research on Dementia Pugilistica has brought two primary things to light. First, although the disease was long thought to be an acceleration of normal aging, perhaps a form of Alzheimer's disease brought on by trauma, the evidence proves otherwise. Alzheimer's disease produces scarring diffusely throughout the brain, but autopsy studies of ex-boxer's brains show a very different pattern of injury. In boxers' brains the scarring is predominantly along the surfaces of the brain, most commonly along the frontal and temporal lobes where punches have led to repeated contact between the bony prominences of the inner skull and the delicate surface of the brain.

The second important modern discovery regarding boxers' dementia is that it is not limited to boxers. Former rugby players, football players and wrestlers such as Chris Benoit have all been known to suffer from neuro-psychiatric diseases similar to boxers. Modern autopsy studies have proven what was long suspected -- these athlete’s brains have the same lesions as Dementia Pugilistica. The term Dementia Pugilistica, applying only to “pugilists,” is outdated: The disease is now known as Chronic Traumatic Encephalopathy (CTE).

This has been a watershed moment: Boxer's dementia has been rebranded and mainstreamed. No longer is CTE fight sport's dirty little secret. With Hall of Fame NFL players speaking openly about their disease, with autopsy studies on 18-year-old football players showing pathognomonic brain scarring, CTE can no longer be marginalized.

It’s well known that the NFL has recently taken an active interest in CTE. Less well known is that the science behind the NFL’s new concern comes primarily from fighters. The NFL’s appropriation of boxing’s brain damage data is well founded; skull accelerations in head punches are similar to football collisions -- 50-80 g's. That bears repeating: These athletes’ brains endure jolts 50 to 60 times the acceleration of gravity. Until recently football apologists argued that their sport was safer than boxing because of the relative paucity of knockouts and the use of helmets. These arguments have been proven to be fatuous. Helmets offer only a fig leaf of protection to acceleration, and sub-knockout concussions -- being “dazed” or “dinged” -- have been strongly implicated in CTE.

This last datum is the most worrisome for fighters. Even blows to the head that don’t cause a knockout -- the euphemistically named minor traumatic brain injury (MTBI) -- cause cumulative permanent damage. In Terry Norris’ pro career, he suffered only a handful of knockouts. But in his whole career, all 351 fights, it is impossible to know how many head blows and low-grade concussions he endured. And it is that data that may be the most important. For any competitor in fight sport the number of blows to the head is incalculable: uncounted hours of sparring, amateur fights, professional fights -- even a short career entails tens of thousands of MTBI events. How many blows to the head has Couture endured? Nogueira? Wanderlei Silva?

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It is true that there is compelling evidence that MMA is safer than boxing. But “safer” is not safe. MMA fighters are starting younger, are enticed by the money involved to fight longer and eventually MMA will have a cohort of neurologically impaired veterans of its own. With the overwhelming medical, scientific and epidemiologic evidence that a career worth of head blows leads to CTE in one out of five fighters, the moral imperative for some meaningful change is inarguable. The sport is too good not to be better.

Unfortunately, even if the need for greater safety is clear, what actually can be done to lessen the danger of CTE in combat sports is less certain. Football or rugby can adapt new equipment or rules to lessen the danger; fight sport has less clear options. In general, most of a fighter's head blows -- if not the most severe -- will occur during training, out of reach of promoters and athletic commissions. Heavily padded gloves may paradoxically worsen the danger. Headgear appears to be of limited use, may even be harmful and, in any event, is unpopular with fighters and fans alike.

Further, it is difficult to stop what cannot be demonstrated to exist in real-time. Pre-autopsy testing for MTBI is effectively unavailable. The commonly used CAT scan -- which does show bleeding -- does not show MTBI. Blood tests for evidence of brain injury are unreliable, and lumbar puncture testing is impractical. The long delay between traumatic insult in a fight and onset of symptoms means that a fighter who shows no quantifiable evidence of injury during his career can still develop CTE at a relatively young age.

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Almost certainly the greatest barrier to preventing CTE in fight sport will be the tolerance of promoters and fans. Violence sells. A Google search for "Top 10 MMA Knockouts" produces 60,000 hits. A search for "Top 10 MMA well-fought three-round decisions" is strangely silent. The violence is promoted and well compensated, the harm it causes de-emphasized and well hidden.

But there is reason for hope: The Nevada State Athletic Commission vice chairman mentioned in this article who was so disturbed by Terry Norris' fight-related brain damage is a familiar figure to fight fans: Mr. Lorenzo Fertitta. I understand he has some pull in the world of MMA. We shall see how he uses it.

Matt Pitt is a physician with degrees in biophysics and medicine. He is board-certified in emergency medicine and has post-graduate training in head injuries and multi-system trauma. To ask a question that could be answered in a future article, e-mail him at mpitt@sherdog.com.
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