What you need to know about Parkinsonism Pugilistica: The Punch Drunk Syndrome

Release date: 7/8/2013

A new television series appearing on Showtime, Ray Donovan, includes a character who exhibits Parkinsonian symptoms. The show attributes this to the character's past career as a boxer. Do you know the difference between Parkinson's disease and Parkinsonism Pugilistica? Dr. Michael S. Okun, NPF's National Medical Director, explains that and more in this special NPF statement.

What is Parkinsonism Pugilistica?

In the 1920’s a pathologist named Harrison Martland described, in a classical article published in the Journal of the American Medical Association (JAMA), a syndrome that was associated with repeated head injury particularly within former boxers.  Many physicians and scientists followed this seminal report over the ensuing decades by better characterizing this syndrome, and importantly by clarifying that it can occur in anyone with repeated head trauma.  The most important finding was that it was not exclusive to boxers.  The potential symptoms included memory problems, behavioral issues, paranoia, and other features such as hallucinations.  In cases where the predominant symptoms were related to thinking or behavior, the term Dementia Pugilistica was used, although some people have coined the term “punch drunk” to describe the behavioral features.  Punch drunk was also a term used in Martland’s original description.  In cases where tremor, stiffness, slowness, walking problems, or balance issues dominated the clinical picture, the term Parkinsonism Pugilistica has been utilized.  The syndrome should however, not be confused with regular Parkinson’s disease, which is a slowly progressive neurodegenerative disorder associated with motor and non-motor symptoms.  Regular Parkinson’s disease, unlike Dementia and Parkinsonism Pugilistica, is responsive to dopaminergic therapies.

What is the difference between Parkinsonism Pugilistica and regular Parkinson’s disease?

Parkinsonism pugilistica is thought to occur as a result of repeated blows to the head, and in some cases can result from multiple bad concussions.  Most cases of the syndrome have been referred to in the scientific literature as Dementia Pugilistica.  It is somewhat rare to observe the classical parkinsonian features of regular Parkinson’s disease associated with this head trauma related syndrome.  It is possible however, to observe some overlap symptoms (tremor, stiffness, slowness, walking issues) with the behavioral features.  The pattern and temporal occurrence of cognitive problems, and also the poor response to dopaminergic therapy can help one to distinguish Parkinsonism Pugilistica from regular Parkinson’s disease.  One should not assume that just because a person was a past boxer that they suffer from Dementia or Parkinsonism Pugilistica, or both.

How are Parkinson’s disease and Parkinsonism Pugilistica related to head trauma?

There are a number of epidemiological studies that have linked Parkinson’s disease risk to a history of head trauma.  If you already suffer from Parkinson’s disease, you should not worry too much about these large association type studies, as the treatment is the same for regular Parkinson’s disease, with or without a history of head trauma.

Parkinsonism Pugilistica can result from repeated blows to the head, regardless of the source of the impacts; it does not only affect boxers.  Recently, much press has been given to former NFL players, especially those with repeated head trauma, and coincident symptoms of Dementia and Parkinsonism Pugilistica.  Athletes from other sports, such as hockey, have also shown signs of Dementia and Parkinsonism Pugilistica.  It is important to keep in mind that in some cases have not been due to Dementia or Parkinsonism Pugilistica despite similar symptoms. .

Selected References:

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  2. Gavett BE, Stern RA, McKee AC. Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clin Sports Med. 2011 Jan;30(1):179-88, xi. doi: 10.1016/j.csm.2010.09.007. Review. PubMed PMID: 21074091; PubMed Central PMCID: PMC2995699.
  3. McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte ET, Gavett BE, Budson AE, Santini VE, Lee HS, Kubilus CA, Stern RA. Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol. 2009 Jul;68(7):709-35. doi: 10.1097/NEN.0b013e3181a9d503. Review. PubMed PMID: 19535999; PubMed Central PMCID: PMC2945234.
  4. Jordan BD. Chronic traumatic brain injury associated with boxing. Semin Neurol. 2000;20(2):179-85. Review. PubMed PMID: 10946737.
  5. Mendez MF. The neuropsychiatric aspects of boxing. Int J Psychiatry Med. 1995;25(3):249-62. Review. PubMed PMID: 8567192.
  6. BRANDENBURG W, HALLERVORDEN J. [Dementia pugilistica with anatomical findings]. Virchows Arch. 1954;325(6):680-709. German. PubMed PMID: 13226712.
  7. Martland HS (1928). "Punch Drunk". Journal of the American Medical Association 91 (15): 1103–1107. doi:10.1001/jama.1928.02700150029009

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