The Rising Awareness of Dementia in Sport: From “Punch Drunk” to CTE
The world of contact sports has a long history with head injuries, one that has evolved significantly in recent decades.
What was once dismissed as “punch drunk” syndrome, an almost expected outcome for boxers, has now been recognised as a serious neurological condition with life-altering consequences.
The conversation around sports-induced dementia has grown louder, spanning across sports like American football, football (soccer), rugby, and boxing, and it’s prompting major sports organisations, governing bodies and researchers to take notice.
This article delves into the origins, research, and current understanding of dementia in sports.
From "Punch Drunk" to Chronic Traumatic Encephalopathy (CTE)
Often boxers, who displayed signs of confusion, memory loss, and unsteady gait, were referred to as “punch drunk.”
Nearly a century ago, athletes, particularly boxers, who displayed signs of confusion, memory loss, and unsteady gait, were referred to as “punch drunk.”
This colloquial term eventually evolved into "dementia pugilistica," a term specifically describing the neurodegeneration in boxers caused by repetitive head trauma.
Today, the condition is known as Chronic Traumatic Encephalopathy (CTE). While CTE is still without a fully agreed-upon diagnostic criterion, it is broadly understood to result from repeated brain injuries and is associated with symptoms like confusion, memory loss, mood changes, and eventually, dementia.
CTE has since been identified in a range of contact sports, beyond boxing to include American football, soccer, rugby, and even wrestling. Researchers have noted that while CTE remains most prevalent among athletes, it has also been observed in individuals from other high-risk groups, such as military veterans exposed to repeated blast trauma and even victims of domestic violence.
The Cost of Football Glory? Dementia in Professional football Players.
The link between dementia and football (soccer) has gained significant traction in recent years.
Retired professional footballers have a 3.5 times higher likelihood of developing neurodegenerative conditions. According to research in the FIELD study (published in JAMA)
Notably, five members of England's legendary 1966 World Cup-winning team—Nobby Stiles, Jack Charlton, Martin Peters, Ray Wilson, and Sir Bobby Charlton—developed dementia later in life.
These cases sparked widespread discussion about the potential long-term effects of repetitive heading and concussions on players' neurological health.
FIELD Study (2021)
In 2021, the FIELD study (published in JAMA) offered groundbreaking insights into the risks that professional footballers face. Commissioned by the Football Association (FA) and the Professional Footballers' Association (PFA), this research by Glasgow University compared former Scottish professional players to the general population.
The findings were alarming: an in 18 year follow up, retired footballers had a 3.5 times higher likelihood of developing neurodegenerative conditions (than the general population).
Additionally, the study showed that defenders, who typically head the ball more than other players, were at higher risk than goalkeepers. Those players with longer careers were also identified at higher risk.
FOCUS and Related Studies
The FOCUS study (Sports Medicine, 2023) followed on the FIELD study's findings, confirming that athletes with a greater history of heading and concussions faced increased risks of developing dementia.
Ongoing research projects, such as the HEADING and SCORES studies, continue to analyse concussion frequency, heading impacts, and the cognitive decline rate in retired footballers compared to the general population. These studies are vital for shaping guidelines that could potentially reduce dementia risk in future athletes.
Dementia in Retired Rugby Players
Rugby has also witnessed a rise in early-onset dementia cases among retired professional players.
In 2023, a group of 260 former rugby players, including notable names like; Dafydd James, Alix Popham, and Steve Thompson, launched a lawsuit against World Rugby, the Welsh Rugby Union, and the RFU, citing negligence for not protecting players from the risk of neurodegenerative diseases.
The evidence of CTE among rugby players underscores the impact that repeated tackles, scrums, and collisions can have on long-term brain health.
Evidence of CTE among rugby players underscores the impact that repeated tackles, scrums, and collisions can have on long-term brain health.
Understanding Chronic Traumatic Encephalopathy (CTE)
CTE remains a challenging disease to diagnose, with no universally accepted criteria or specific threshold of trauma known to trigger it.
The condition is known for its progressive nature, where symptoms often worsen over time.
There are four stages of CTE, which typically begin with;
confusion
disorientation,
and headaches, and can advance to more severe cognitive impairments
Such as;
memory loss,
impulsivity,
poor judgment,
depression and movement disorders.
In the final stages, individuals may develop;
progressive dementia, along with
tremors,
vertigo,
and even sensory processing disorders.
CTE and Brain Pathology
“CTE remains a challenging disease to diagnose, with no universally accepted criteria or specific threshold of trauma known to trigger it. ”
An indicator of CTE is brain atrophy, particularly in the frontal and temporal lobes, which are responsible for decision-making, memory, and emotional regulation. In affected brains, researchers have identified abnormal protein deposits known as p-Tau and neurofibrillary tangles. Although these proteins are also present in Alzheimer's disease, the pattern and distribution in CTE are unique, further confirming that this is a distinct disorder with its own pathology.
Toward Safer Sports Practices?
The rise in dementia cases among former athletes highlights a pressing issue for contact sports: the need for better protective measures and early intervention strategies.
While there is no easy solution, the FIELD and FOCUS studies, along with ongoing research, provide invaluable data that can inform policy changes, such as limiting heading in soccer training or adopting stricter concussion protocols in rugby and American football.
For athletes, coaches, and governing bodies, the challenge lies in balancing the love of the game with the need to prioritize health and safety. With increased awareness and a commitment to science-based changes, sports can continue to thrive while minimizing long-term health risks for players.
New Studies. Do you know someone who could help?
The PREVENT Sport study is recruiting previous elite/professional footballers (male and female) as part of a study in collaboration with Glasgow University to try and identify risk factors and aim at reducing future risk.
If you would be interested in participating in the study and have a history of playing elite or professional football please follow the link below and sign up.
Article based on 2024 presentation
Dementia and Sport:
Written by Dementia Trust Trustee and Consultant Psychiatrist: Dr. Katherine Paramore
