Sports Medicine Rehabilitation In Boxing

Sports medicine and rehabilitation has taken on greater importance in boxing today. The issues of injury prevention, education and conditioning of athletes, and the treatment of injuries- fractures, dislocations, intracranial bleeds are of major importance within the sport of boxing.

Proper assessment and treatment of boxing injuries require an understanding of boxing specific musculoskeletal and neurological injuries.

The value of an inter disciplinary approach to boxing to include physical therapists, massage therapists, certified fitness trainers and nutritionalists is important to the approach of providing comprehensive health care to the boxer athlete.

The mission of sports rehabilitation is to rehabilitate the injured boxing athlete beyond the resolution of symptoms in order to allow a medically safe return to the sport and prevent further injury

Physician

The ringside physician is a physician licensed in medicine who has a broad understanding of common boxing injuries as well acute emergencies. Ringside physicians are presently participating on a voluntary basis.

The role of the ring physician is to ensure the participant safety and ability to perform in this contact sport. A background in sports medicine is an attribute for a ringside physician.

The preferred physician should be a medical doctor or doctor of osteopathic medicine and have proof of a current medical license as well as medical malpractice insurance. He should be able to be in good standing at a local hospital and familiar with the nearest hospital emergency room to the boxing arena.

Communication between the local emergency medical trauma team and the ringside medical staff is critical in managing acute life-threatening injuries.

Rehabilitation

Boxing injuries can be divided into two basic types- those resulting from acute trauma and those resulting from chronic repetitive microtrauma. Each type of injury has certain specific characteristics and findings that are associated within the evaluation process.

The difference between acute and chronic injuries lies in the fact that acute injuries occur from a one-time event and are easily recognizable, whereas chronic injuries usually present as a gradual onset with increasing symptoms. In the chronic injuries, the exact timing of the onset of injuries usually less exact since symptoms may be more widespread and may be initially easily overlooked

For both types of injures rehabilitation is an important process that promotes healing and restoration of functional capabilities. Principles of Rehabilitation There are three major phases that exist in the rehabilitation process: the acute, the recovery, and the maintenance phases.

The goal of rehabilitation includes the return of tissue healing, maintenance of fitness, resolution of the injury cycle, and restoration of functional endurances and flexibility to return back to the sport.

In the acute phase of rehabilitation modalities should be used to reduce the signs of acute inflammation and injury. Modalities such as ice, heat, hydrotherapy, electrical stimulation work to decrease the swelling and facilitate tissue healing. Anti-inflammatory medications, splinting and surgical treatment are all utilized in this phase of rehabilitation.

Recovery Phase of Rehabilitation

The recovery phase is often the most lengthy and most involved phase of rehabilitation.  Emphasis in this stage shifts from resolution of clinical symptoms to restoration of function. Anti-inflammatory medication and physical therapy modalities are use much less frequently and assume a more adjunctive role.

Appropriate tissue loading is the major modality that is used in this phase. As tissues regain their integrity, flexibility is increased and strength improved through isometric and isotonic exercises and then isokinetic rehabilitation.

Isometric exercise increases strength quickly essentially through no movement, (i.e., pushing against a wall). The disadvantage of isometrics is that strengthening does not occur through the full range of motion, therefore flexibility and conditioning are not promoted.

Isotonic exercise promotes muscle conditioning through movement. Calisthenics and weightlifting are common examples of isotonic exercises. In isotonic strengthening, muscles are loaded with increasing increments to promote both strength and endurance.

The disadvantage of isotonic exercises is that these exercises are not specific in promoting cardiovascular fitness.

Isokinetic exercise promotes strengthening and flexibility through a range of motion for which a maximal force is given at every point within this range of motion. Isokinetics frequently involve specialized machines that match the strength through every degree of motion. This form of strengthening and exercise is very effective for it provides a constant load on the muscle allowing the athlete to achieve the highest level of performance.

An adjunct to isometric, isotonic and isokinetic exercise strengthening program is aerobic fitness. Aerobic exercises improve cardiovascular fitness by increasing the heart rate, which promotes positive physiological changes on the cardiovascular and respiratory systems.

Aerobic exercise should be targeted for a minimum of 15 minutes to increase the heart rate within the desired target training level.  In addition to modalities and exercise, the therapist may add to their rehabilitation, regimen using assistive devices.

Taping, braces and splints are frequently utilized in acute trauma. Therapeutic massage has also been utilized as a modality in acute injuries. Massage has been shown to be beneficial in improving the stretching of tendons and connective tissue providing relief of muscle tension and spasm. Massage enhances muscle recovery from intense exercise as it improves muscle blood flow

Recovery Phase of Rehabilitation

The recovery phase is usually the longest and most involved phase of rehabilitation. The emphasis of this phase is the resolution of clinical symptoms and restoration of function.  Within this stage, anti-inflammatories and modalities are much less frequently utilized.

As recovery of muscular tissues is achieved, strength and flexibility are the focus of the rehabilitation. Concentric and eccentric muscle strengthening as well balance are emphasized.

Maintenance Phase of Rehabilitation

The maintenance phase is the final phase of rehabilitation and helps prevent future injury. In this phase, the athlete is prepared to return back to his level of athletic performance.  Simulated activity within the sport’s specific motions should be evaluated for any weaknesses and strength, lack of flexibility or pain.

Protective equipment should be used to prevent any recurrent or new trauma during this phase of rehabilitation. Criteria to return back to athletic ability and training should be strict and include the following components: no pain, full range of motion, strength being equal on opposite sides, strength balance within the expected norm for the sport, and a completion of the functional interval progression of activities.

Acute Exacerbation of Chronic Injury

Acute exacerbation of chronic injury is difficult to distinguish from acute injuries. An athlete may assume that the injury was completely healed and then, through activity, have an acute exacerbation. It is up to the healthcare practitioner to differentiate between a new trauma and a re-aggravation of an underlying chronic condition.

Treatment of the acute episode overlying a chronic problem involves the same recovery phases as acute injuries. Identifying specific anatomical or physiological trauma is more importantly the key to minimizing the degree of permanent injury.

Common Boxing Injuries at Olympic and Amateur Level

A 15-year record of injuries and illnesses of amateur boxers at the Untied States Olympic Training Center in Colorado Springs was reviewed by Dr. Timm, et al. (2). Although there were significant differences between the frequency of injuries and illnesses collectively, the serious injuries represented only a relatively small percentage (6.1 %).

The most common involved the upper extremity representing 25%, second most common were head and face injuries, representing 19%, third were lower extremity injuries, representing 15% and finally spinal column injuries representing a 9% incidence.

This study, followed by Dr. Timm, found the most common injury was a contusion representing 24.90/0, followed by muscle strains representing 20.8%, joint strains 17.5%, tendonitis 9.2%, concussion 6.1 % and fracture 4.9%.

The probability of injuries recurring is great if the athlete returns prior to completing rehabilitation. In order to ensure a safe recovery, five criteria should be met before participating in full physical activity: I) Absence of pain; 2) Full range of motion at the injured area; 3) Normal strength and size of the injured area; 4) Normal speed and agility; 5) Normal level of fitness.

Absence of pain

In the acute phase of injury, pain usually disappears within a few days for a bruise or minor sprain. For more serious injuries, the pain may remain for days or weeks. The main goal of rehabilitation is to resolve pain, reestablish normal range of motion, strength and power and muscular endurance at the site of injury.

Full range of motion

Musculoskeletal injuries reduce range of motion at the joint. The more severe the injury, the greater loss of range of motion. As soon as the athlete is able to move an injured area, the athlete should be encouraged to progressively increase the range of motion until normal range is achieved.

In regards to appropriate stretching over the past two decades, many experts have advocated prolonged stretching anywhere from 30 seconds to 20 minutes for what was termed the optimal stretch. For years, this prolonged static stretching technique was the standard.

However recently, studies have shown prolonged static stretch greater than five seconds actually decreases the blood flow within the tissue creating localized ischemia, increased lactic acid buildup and lymphatic stasis.

With appropriate isolated interval stretching, full range will eventually return. When an athlete can move the injured muscle or joint through its normal range, strengthening exercises should begin.

Muscle strength and size

After an injury, muscle disuse or atrophy occurs from splinting, wrapping, and resting the affected muscle groups. As a result of disuse, muscles become smaller and weaker than they were before the injury. Strengthening of the injured muscle group should be done conservatively and with weighted increments. Weights should be incorporated to a level of pain tolerance. If the weight utilized creates significant pain levels, then one should return back to a lighter weight for the strengthening program.

Assessing full strength and size is best when compared to the uninjured area on the opposite side of the body. When both areas are equal size and strength, then the athlete may progress to the next phase of recovery, which is competitive practice.

Speed and agility

Once the athlete has regained full strength through the entire range of motion, he is ready to return to practice competition.  Returning to practice, the athlete progresses with the intensity and duration of the activity.  It is important for the trainer to specifically monitor

and observe the previously injured body part.  When an athlete can move at a pre-injury speed and agility, he is potentially ready to compete again.

Level of fitness-conditioning

Fatigue and injury have a strong relationship. When an athlete becomes fatigued, his skill performance is reduced. Concentration becomes more difficult, and reaction times slow down. As the athlete’s judgment becomes impaired, faulty decisions are made which result in injuries.

One of the final phases of sports medicine and rehabilitation is to improve performance and conditioning. The conditioning program is designed to minimize fatigue and potential for injury. Similarly, coaches and trainers must be aware that athletes will engage in intense, frequent practices and bouts. They athletes require time off. It is possible to over-train and cause, rather than prevent, injuries.

Injuries caused by overtraining are at an increasing proportion within all sports injuries. Signs and symptoms of overtraining and potential for injuries include: .elevated resting heart rate .chronic muscle soreness .poor performance .higher incidence of injury .longer time to recover from injury Warm-up.

The body responds optimally when proper physiological responses are coordinated. The body requires a controlled warm-up period to prepare itself physiologically with optimal body temperature, increased blood flow and neurosensitization. This physiological response promotes greater tissue pliability with more effective and efficient neuromuscular functioning.

Cool-down Period

Muscles in the body tighten during periods of inactivity following hard work. To minimize muscle stiffness and the soreness, 20 minutes should be dedicated to adequately cool down at the end of the practice. A gradual reduction of activity (the reverse of the warm-up procedure) facilitates removal of the body’s waste products associated with intense muscular activity.

Taras V. Kochno, M.D.

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Concussion is a common problem in sport; participate in a contact sport and it’s estimated that on average you’ll require injury treatment for concussed once for every 4,000 hours of sport you play at best and once every 200 hours at worst! John Bye explains what concussion is and answers some of the questions frequently asked by athletes who have suffered from concussion.

What is concussion?

In 2004, the Second International Symposium on Concussion in Sport (the most recent meeting of international experts in the field) defined concussion as ‘a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces’(1). Put more simply, concussion is the way the brain responds to a ‘bump’. A ‘bump’ is really any significant force that passes through the brain – an uppercut in boxing, a clash of heads in football or a cyclist going over the handlebars onto the ground are a few obvious examples of direct blows to the head or face.

Less obvious are indirect blows where the force is transmitted up to the head from another part of the body; a good example is that of a stationary rugby player tackled from behind, his neck flicking back and some of the force of the tackle passing through his brain. He may end up concussed without ever taking a direct blow to the head.

Both direct and indirect bumps cause the brain (an organ with the consistency of jelly that is effectively suspended by a set of strings) to be shaken about inside the skull (a tight-fitting, hard box). There is an obvious potential for injury if you consider the brain in this way.

Concussion is the brain’s response to a significant bump and manifests itself as a range of symptoms and signs such as headache, confusion, amnesia, drowsiness, dizziness, balance problems, slurred speech and feeling sick.

There are two subtypes of concussion(1):

Simple concussion – characterised by an uneventful progressive recovery within seven to 10 days with rest being the most important component of management. Most concussions fall into this category.

Complex concussion – where recovery takes longer than seven to 10 days and/or is complicated by problems such as fits, recurrence of symptoms associated with exercise or prolonged unconsciousness.

By definition, the brain is not functioning normally in a concussed athlete. However, the experts are divided as to why the brain is not functioning properly – is structural damage to the brain the cause of concussion or is concussion a purely ‘functional’ problem? To understand these arguments, it’s necessary to have a basic understanding of the structure and function of the human brain.

Concussion controversy

Advocates of the structural damage theory of concussion often talk about a cumulative effect of one concussion after another. If concussion were due to structural damage, we would certainly expect a cumulative effect given what we know about neurones being unable to repair themselves.

The British Medical Association (BMA) seems pretty convinced of a cumulative effect, having made the case for a boxing ban on this basis since the early 1980s. ‘Punch-drunk’ syndrome is a recognised phenomenon in older and retired professional boxers that has been attributed to repeated punches to the head. However, the BMA admit in their August 2006 position statement on the subject that relevant research studies have significant weaknesses and a recent article in the British Journal of Sports Medicine failed to show any cumulative effect for people with one or two previous concussions (although the authors admit that damage could have been missed by their assessment methods)(2). More research is needed in this area before any firm conclusions can be drawn.

More scientific evidence that structural damage does occur in even very minor impacts (below those required to cause concussion) comes from a study which looked at blood levels of SB-100 (a protein that exists in a certain type of neurone) and NSE (an enzyme found in neurones) in female football players before and after a match(3). When neurones are damaged, they spill SB-100 and NSE into the blood; this study showed that blood levels of both chemicals rose the more players headed the ball, suggesting that an impact as small as heading a football damages the structure of neurones.

Those who consider concussion to be a predominantly functional disturbance with little or no underlying structural damage cite a set of clinical symptoms and signs that are usually short-lived, recover spontaneously and fully, and that don’t fit with what would be expected from structural damage to a specific area of the brain. They also point to a set of symptoms, which in the short-term are more severe than would be expected from the minimal structural damage for which we actually have reasonable scientific evidence. This suggests that there must be a large functional component to concussion.

Head scans using magnetic resonance imaging (MRI) and computer topographic (CT) usually demonstrate normal structure in patients with concussion. Functional MRI (fMRI) scans have been shown to be abnormal in concussed sportspeople(4). However, it should be emphasised that MRI, CT and fMRI scans do not rule out structural damage; it may be that microscopic structural damage, too small for a CT or MRI scan to detect, is responsible for the functional impairment.

Assessing and managing concussion

Distinguishing concussion from a more serious, possibly life-threatening, brain injury as well as ruling out the presence of damage to the spine that could have happened at the same time as the head injury are the first priorities of management. These tasks are often far from straightforward and it is prudent to assume the worst – you should avoid moving the casualty and request emergency medical attention if you are at all uncertain. Concussed sportspeople should not be allowed to continue competing or training until they’ve been medically cleared.

Once serious brain and spinal injury have been excluded and the athlete has been removed from the field of play, a suitably qualified person such as a doctor or sports physiotherapist, should assess the severity of concussion. Problems such as fits, significant drowsiness or deterioration may warrant admission to hospital for observation.

Even if you have been medically cleared, you should not be left alone for the first 48 hours and should go to hospital immediately should any of the following occur:

Worsening headache

Vomiting more than once

Problems recognising objects, people and places

Numbness or weakness in your arms or legs

Feeling unsteady on your feet

Slurring your speech.

You will need a companion to look after you for 48 hours in case any of the following problems (which you won’t be able to notice yourself) occur:

You have a fit

You start behaving differently or irrationally

You cannot be woken up.

Neuropsychological tests

Concussion can result in subtle but important changes in mental function. A number of assessment tools (collectively referred to as neuropsychological tests) have been designed to help athletes, coaches and medics to identify, grade and monitor recovery from concussion. These tests take a variety of forms, from simple pen and paper questionnaires to complex software programmes. Two of the simpler and more widely used tests are shown in boxes 3 and 4. It should be noted however that neuropsychological tests are only an aid to assessment and that they should not replace or preclude proper medical care.

Neuropsychological testing is an important part of a concussed athlete’s medical assessment. Athletes are generally eager to return to sport and have a tendency to under report and underestimate symptoms caused by concussion, possibly endangering their prompt recovery and health. Neuropsychological tests offer an objective method of assessing recovery from concussion and have been recommended as the ‘cornerstone’ of understanding the injury and managing the individual particularly in cases of complex concussion(1). An athlete’s neuropsychological tests should return to a baseline level (taken at the start of the season) and the athlete should be symptom free at rest and on exertion before returning to the field of play.

Recovery from concussion and return to sport

The golden rule of sport concussion is that the player should not be allowed to return to sport until they have completely recovered. Why not? To prevent the following problems:

Another injury to the head or body being caused by the incompletely recovered athlete being clumsy or slow;

Injury to another player for the same reason;

Post-concussion syndrome;

Second-impact syndrome.

‘Post-concussion syndrome’ is the term used to describe symptoms such as dizziness, fatigue and problems with concentration and memory, which can persist for weeks, months or even years after concussion. Post-concussion syndrome requires thorough investigation by a suitably qualified healthcare professional, although treatment is limited to rest and reassurance. Sport and exercise may prolong the condition and are therefore inadvisable.

‘Second-impact syndrome’ is a catastrophic condition where a person who hasn’t fully recovered from a concussion sustains another minor head injury, leading to massive and often fatal swelling of the brain. However, there’s doubt that this condition actually exists(6). If it does, it’s certainly rare – one study counted just 35 unconfirmed cases in 13 years of American football(7).

The length of recovery from concussion is very variable – from minutes to months – and there is little that can be done to speed recovery. It is recommended that concussed athletes refrain from sport for at least the rest of the day of the injury as an absolute minimum, even if they’re apparently fully recovered. The exception to this is the professional athlete who may have immediate access to appropriately qualified people with ample resources to properly assess them. Any athlete who has suffered a concussion should ideally make a gradual, graded return to exercise before returning to competitive sport under close observation to ensure that their recovery is indeed complete. Some sports such as boxing apply a minimum period of exclusion for those who are concussed but there is no good evidence for such rules – some people may need more time than the obligatory exclusion period for recovery, some less.

Concussion in children

There are currently no guidelines for the assessment and management of concussion in children. Children differ from adults in a number of important ways when it comes to concussion. Surprisingly, it is estimated that children require an impact force two to three times greater than that in adults to cause a concussion with the same symptoms(8). This may be because a child’s head is more resilient to force, having a different structure to that of an adult, or it could be that a child’s response to a bump is different to an adult’s. The different structure of a child’s brain and skull also makes them prone to the rare but potentially life-threatening complication of brain swelling. On the plus side, children with concussion appear to recover faster than adults.

So should you assess children in the same way as adults? Many do because of the absence of alternatives, but you should exercise caution. Neuropsychological testing in children is not as accurate as it is for adults because children are developing and their test results should be improving as they age, especially between the age of nine and 15 years. A child whose neuropsychological test result after a concussion is the same as it was before could actually have suffered significant damage if the baseline was done pre-season and the concussion sustained at the end of it. Children involved in contact sports might benefit therefore from regular baseline tests every six months rather than yearly.

Finally, children with concussion do not normally require any investigations such as skull x-ray, CT or MRI scan. As with adults, the ideal management is careful observation, rest and a graded return to exercise once symptoms have resolved.

Summary

Concussion in sport is common; the golden rule of its management is that athletes should not return to sport until they have made a full recovery. Distinguishing between concussion and more serious injuries can be difficult. In the case of suspected concussion, athletes and their coaches would be well advised to seek medical attention sooner rather than later.

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Cardiomyopathy is a condition in which the muscle of the heart is abnormal in the absence of an apparent cause. This terminology is purely descriptive and is based on the Latin deviation. HCM is a primary and usually familial cardiac disorder with heterogeneous expression, unique pathophysiology, and a diverse clinical course, for which several disease causing mutations in the genes encoding proteins of the cardiac sacomere have been reported. There are some forms of HCM, that are currently being debated by the medical community regarding how they should specificly be defined because the causethe hypertrophy in these cases is now understood to be from other mutations impacting either the storage of glycogen or lysosomal storage within the heart.

While HCM has typically been recognized by its structure ie., hypertrophy, the electrical function of the heart are also adversely affected. There are four types of cardiomyopathy:”hypertrophic”, ”dilated”, ”restrictive” and “right ventricular”.

The main feature of hypertrophic cardiomyopathy is an excessive thickening of the heart muscle (hypertrophy literally means to thicken). Thickening is seen in the ventricular septal measurement (normal range .08-1.2cm), and in weight. In HCM, septal or wall measurements may be in the range of 1.3cm to 6.0+cm anywhere in the left ventricle. Heart muscle may also thicken in normal individuals as a result of high blood pressure or prolonged athletic training. Furthermore, there is a fine line between and athletic heart, hypertensive heart disease and a heart with HCM.

In Hypertrophic Cardiomyopathy (HCM), the muscle thickening occurs without an obvious cause. In addition, microscopic examination of the heart muscle in HCM is abnormal. The normal alignment of muscle cells is absent and this abnormality is called ”myocardial disarray”.

http://www.4hcm.org/

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When I lived in Tennessee, one of my closest friends was Don Arwood MD, a past Golden Gloves champion. In 2003, my own student Josh Durham, a current Golden Gloves heavyweight champion, invited me to be the volunteer ringside physician at a match. I was impressed with the concern that everybody showed for the young people and their safety. I have chosen to continue my involvement.

Whatever “consensus documents” my professional colleagues draft, there will always be many young males who want to engage in amateur boxing. This is in spite of much concern, by physicians and others, that amateur boxers could get the same kind of brain damage that is so familiar in professional career boxers.

In my opinion, the health risks of today’s amateur boxing, properly supervised, have been exaggerated badly enough to justify my speaking out in the sport’s defense.

Of course, here and everywhere, I’m speaking only for myself.

I have no intention of discussing the “moral issues” in a sport where the object is to hit your opponent. The ways in which boxing is like, and unlike, contact sports such as hockey or American football are obvious. In particular, George Lundberg MD, a fellow-pathologist, has taken a very strong stand against all boxing as inherently both unsafe and immoral. Many decent people will agree, and I’m basically with him on professional boxing.

On the other hand, many young men (and some young women) love the boxing milieu, and find it to be their preferred environment for staying physically fit and for building friendships. Better in the ring than in bars or drug-houses. And like it or not, in our world, the only way you avoid being badly hurt is for you or a friend of yours to be able and willing to hurt back. Force will always govern human affairs, and the best for which we can hope is that this will be the force of just law. But in areas where the law does not reach — including some places in the U.S. — a young man can live peaceably only if he is known to be able to fight. It’s not nice, but it’s a fact of life.

By temper and upbringing, I’m a man of peace. I have only struck one other person in anger, and he richly deserved it. I surprised myself. I also frightened myself. Since then, I have never even carried a Swiss army knife. So my defense of the sport is not motivated by a bellicose disposition. I have enjoyed doing the boxer’s fitness routine but am not interested in learning to spar. I also skydive. This is an “extreme” sport which has a much higher risk of injury and death than amateur boxing. (The risk is lower for folks like me who always play safe.) But being a skydiver still places me at less risk than the fact that I drive an automobile.

Most any discussion of amateur boxing will include an explanation of the rules that protect the participants. I’m glad to be part of this protection. Especially, today’s amateur boxers are very much aware of second-impact syndrome, and after even the slightest suspicion of a first concussion, there is a mandated month out of the ring. Should it happen again, the intervals are successively longer.

The most important statement by a physicians’ group on amateur boxing is the 1997 policy statement of the American Academy of Pediatrics, through its Committee on Sports Medicine and Fitness. You may find this in Pediatrics 99: 314-5, 1997. The committee acknowledges that the rate of obvious head injury is actually lower in amateur boxing than in football, rugby, or ice hockey. However, the academy singles the sport out for condemnation because “intentional head injury” is the “primary objective”.

According to the academy, “Recent studies have shown that amateur boxers still are at risk for acquiring cognitive abnormalities and/or focal neurologic deficits.” The only science which the academy cites to support this claim is five published studies.

I obtained and reviewed all five papers. Here is what they actually say.

Acta Neurol. Scand. 82: 353-60, 1990.

Swedish physicians Yvonne Haglund and H. E. Persson reviewed boxing safety in Sweden, where professional boxing was banned in 1969, which is fine with me. The medical community could find no reason to ban amateur boxing, but in the mid-1980’s the legislature wanted to outlaw it anyway, and asked the team for some real science. They got the best work so far.

This paper focuses on electrophysiology of the brain. The authors compared boxers, soccer players, and track-and-field athletes. The boxers had slightly more minor EEG anomalies. There were no other differences either on the brain electric activity mapping, auditory evoked potentials, auditory evoked P300 potentials, or anything else.

The authors’ chief concern was based on statistics for the old-fashioned EEG’s: No signs of serious chronic brain damage was[sic.] found among the amateur boxers or the soccer players and the track and field athletes. However, it cannot be excluded that the EEG differences between the groups may be a sign of slight brain dysfunction in some of the amateur boxers. Of course, the effect on EEG’s, even if real, may have been the transient effect of recent sparring, or the remote effect of heavier drug or alcohol use, or injuries from a rougher past. There’s really no way to sort this out.

Am. J. Sports Med. 19: 376-80, 1991

. [The Academy wrongly cited the volume number as 91.]

Three researchers (one from Chicago’s Rehabilitation Institute where I did some of my own training) did neuropsychologic tests on boxers just before and just after they competed. The group found that post-fight, the boxers did worse on verbal and incidental memory. However, they actually did better than pre-fight on tests of executive and motor function.

Go figure. When you’ve just stepped out of the boxing ring, you aren’t going to focus on word games. And the authors actually point this out. (”Hyperaroused” is their word. Had it myself. Good feeling.)

It disturbs me that anyone would pretend this means that amateur boxing causes brain damage. The authors merely express the usual doctorly concern and ask for further studies. And they explain at some length that they were aware of NO study correlating any observated neuropsychological abnormality in a group of amateur boxers with either the duration of their careers, or their numbers of fights, or their win-loss records, or whether the referee stopped their fights.

Am. J. Sports Med. 21: 97-109, 1993

Dr. Haglund reviews the work by her own team and others, and offers some new work. Boxers are mostly indistinguishable from non-boxers on scans and personality traits. Interestingly, boxers were actually less impulsive and better socialized than non-boxers. There were more slight or moderate EEG deviations among boxers, and on the average they could not tap their fingers quite so rapidly as other folks. All other neurologic tests showed no differences. Since finger-tapping is mostly a test of cerebellar function, and since the boxers had probably drunk more alcohol over their lifetimes, I’m inclined to blame the past alcohol intake, which is famous for slowing our finger-tapping speed even long after we’ve sobered up. (Ask a pathologist to show you the superior cerebellar vermal atrophy which correlates with lifelong alcohol intake.)

The fact that there’s been no real work addressing the safety of amateur boxing since Yvonne Haglund’s tells me that these findings have persuaded the people who are really concerned with truth.

Int. J. Sports Med. 13: 616-20, 1992

This is the only paper among the five which contains any talk about “focal” neurologic findings. So it’s probably the most important.

Most of the paper describes a completely unsuccessful attempt to find microhemorrhages in the brains of amateur boxers using the new neuroimaging techniques. The authors describe following thirteen boxers and apparently took full histories. No boxer had fewer than 20 fights, and one had over 200. They concluded that five had “focal neurologic signs following the fights” at least once. They emphasize that there was no correlation between the number of head punches and the occurrence of neurologic signs.

So what were the “focal neurologic signs”? Each of the five boxers had at least one episode of transient amnesia. Two briefly “exhibited cerebellar ataxia”. And one complained of impaired vision. All of these disappeared after fifteen minutes or less. And that’s it.

I wish the authors had told us more. There is no explanation of how the examiners decided that the “cerebellar ataxia” wasn’t just common dizziness, like I’ve had after riding a roller-coaster. If there was really cerebellar involvement, every one of my students would have sought and reported coarse intention tremor, past-pointing, and/or some other harder cerebellar sign. If these were present, the fact would be worthy of publication. And the complaint of disturbed vision evidently wasn’t enough even to make the physicians do a quick visual acuity check. If they had, we’d have heard the results.

Now, when a physician speaks of a “focal neurologic sign”, he or she means a hard, localizing neurologic finding. Loss of sensation in the distribution of a particular nerve, loss of vision in a well-defined portion of an visual field, fasciculations of one muscle group, paresthesias down two adjacent dermatomes, or a reproducibly extra-brisk knee jerk on one side are all “focal neurologic signs”. And when a trivial cause isn’t obvious (i.e., numbness after leaning against on a nerve), this suggests some serious nervous system damage.

The authors of this paper are German, and perhaps there is a problem in the translation or the usage in that country is different. But the neurologic findings described here are not “focal neurologic signs” as the term is customarily used in English. (The clumsiness that somebody gets after drinking a few beers is also a cerebellar-type ataxia, and I doubt any physician would call this a “focal sign”.) I checked with a few of my medical colleagues and they agreed.

The Academy changed the term “focal neurologic signs”, used in the article, to the more inflammatory “focal neurolgic deficits”. The charge is serious. And it seems to be baseless.

J. Neurol. Neurosurg. Psych. 50: 96-99, 1987.

A group in Scotland wrote to amateur boxers inviting them to be examined for neurologic deficits. Twenty boxers volunteered, including some who had heard about the study from friends. Seven of the 20 had abnormal EEG’s, all quite different. Oddly, theyounger the boxer, the more likely (p<0.05) the EEG was to be abnormal (as for teens generally), and there was no correlation between EEG abnormalities and boxing history. All had normal CT’s except for one who had dilated ventricles without cortical atrophy. Seven had minor abnormalities on the neurological exams (one with unequal pupils, two with extensor plantar responses, one with slow pupil reactions, one with a head turn, and two with poor rapid alternating movements of the forearms.) Seven of the twenty had some abnormality on “neuropsychometry”; these included “poor visual memory”, “slow reaction time”, “poor verbal memory”, and “poor attention”.

The authors pointed out the glaring flaw in their own study. We must emphasize that it is not possible to conclude from our data that the abnormalities we have found are the result of boxing. It may be that any group of young men examined in this way would have similar findings. In addition our study group may be unrepresentative; it comprised only those who accepted the invitation to be examined and possibly they did so because they had complaints and were concerned. Finally, it could be that men who take up boxing come from a population who already have such abnormalities. Definitive conclusions therefore are not possible.

I think all these interfering factors were probably operating. Actually, I have failure of convergence on close gaze, and would fail my own Romberg test because I once had labyrinthitis. I have seen identical eye and plantar findings on student doctors practicing physical examinations on one another. Although the authors say they eliminated boxers who had been heavy drinkers, I still wonder about alcohol history in people who have slowing of repetitive movements.

The authors add, Caution should be applied to some of the minor neurological signs when they are searched for so intensely. None of the present subjects could be regarded as in any way physically disabled, rather the reverse. Only one had symptoms. With a complete lack of controls or blinds, this study really tells us nothing.

I do not find the Academy’s own sources sufficient to justify their harsh warning about the risks of brain damage from amateur boxing. The lone article that mentions “focal neurologic [deficits]” doesn’t mean what physicians in the U.S. would assume it means. And except for the uncontrolled study where there was selection for people who wanted a neurologic exam, real “cognitive abnormalities” seem conspicuous by their absence. I would invite my readers to obtain the articles themselves via interlibrary loan and find out who’s telling the truth.

To their credit, the Academy also cites two papers where the authors looked hard and could find no effects.

Arch. Neurol. 45: 1207-8, 1988; a negative neuroimaging study;

Acta Neurol. Scand. 82: 245-52, 1990

This is by Haglund again, this time with a team from neuro-psych, again using the soccer and track athletes as controls. and this time a randomly selected group of young men not chosen for athleticism. Probably no one was surprised that the boxers came from lower socioeconomic backgrounds and had done more drugs and alcohol before their sports careers. They supposedly all stopped using while in the sport. In addition to confirming that their test methods showed no sign of chronic brain damage from Swedish amateur boxing, the team found that the athletes from each group seemed better socialized and more disciplined than the non-athletes.

They might also have cited the paper by Porter and Fricker in Clin. J. Sport. Med. 6: 90-6, 1996 (no measurable effect whatever). “There is accumulating evidence that amateur boxing is not associated with chronic traumatic encephalopathy but longer term prospective studies are needed.”

The public is deluged with claims about health risks, real and bogus. Any study is “news”, and today’s public recognizes that many (perhaps most) such claims will soon be discredited. Where the relationship holds up and the risk gets accepted as real by the scientific community, the hazard typically produces a single, easily-characterized illness. And the heavier the exposure, the greater the risk proves to be. Every medical student knows this distinguishes the junk from the real stuff.

I am genuinely concerned about the risks of subtle eye injuries to amateur boxers. Amateur boxing gloves lack the thumbs which used to cause blunt trauma to the eyes. But eye injury is an area where there is still considerable discussion. Older studies show up to 75% prevalence of old eye injury, most especially retinal tears. A newer survey of elite Turkish boxers showed only one of twenty with an eye injury (Br. J. Sport. Med. 36: 428, 2002). The vast majority of these never produce any loss of vision. However, a retinal detachment is catastrophic, and the story of Sugar Ray Leonard is well-known. It would seem wise for the boxer’s primary care physician to do a dilated eye examination at the routine annual physical exam.

“Boxer’s knuckle” is blunt trauma to the metacarpophalangeal joint, usually the first. There are a few papers about its management.

Individuals who choose to participate in amateur boxing know that there is some risk. (And of course, it should always be a free choice.) Especially, I would urge participants to have yearly retinal examinations. The risk of death is commensurate with other risks which we accept routinely. I could find nothing to indicate that amateur boxing (unlike professional boxing) places its participants at measurable risk for long-term brain damage.

Actually, I would much prefer to have my own son participate in amateur boxing than ride a bicycle in downtown Kansas City. I hope you found my notes helpful. And should you or one of your family members choose to box, I hope there will always be a good physician at ringside.

Ringside PHysicians – organization of physicians concerned with safety

Postscript: The Ringside Exams

Each boxer has had a complete physical exam within the previous year, and also gets checked by a physician just before an event. Here’s the pre-boxing checkup that I use, and the thinking behind it.

Take the pulse. Of course, we are really concerned with rhythm. An anxious boxer may have sinus tachycardia, while an aerobically fit boxer may have sinus bradycardia. I would disqualify anyone with more than 5 irregular beats per minute unless there has been a proper cardiology consult.

Take the blood pressure. I would not want someone with a diastolic over 90 to box. Repeat check to rule out white jacket syndrome. A high level of fitness can produce a low blood pressure reading, and such an athlete should not be excluded.

Check pupils, extra-ocular movements, and accommodation. Two flashes in each eye, one to see the direct response, one to see the consensual response. Eyes to their maximum distances in each of the six directions, and convergence to the nasal root. Document whether there is convergence all the way in. This is essential since some people (myself included) have anomalies and if these are noted after a fight without being previously documented, they could generate much confusion.

Palpate the cervical nodes. One doesn’t want to be examining teenagers and missing Hodgkin’s disease or infectious mononucleosis.

Auscultate the heart. The great concern is hypertrophic cardiomyopathy, with its distinctive murmur. Also be sure you have palpated the apex beat with the stethoscope. It’s embarrassing for the doctor to miss situs inversus.

Auscultate the lungs. A mild chest infection could trigger asthma in the ring. If you missed the warning wheezes, you’d be embarrassed.

Palpate for the spleen and liver. A blow to the spleen in the presence of infectious mononucleosis could be catastrophic. And it would be regrettable for the doctor to miss impending hepatitis, a hot gall-bladder, or a right-sided, enlarged spleen.

Examine the neck veins while supine. Boxers may become dehydrated while trying to make weight. If the neck veins are flat, instruct the boxer to drink a few glasses of water (or better, an electrolyte beverage). “You’re a quart low.”

Test the gait. Include tiptoe, heels, and tightrope.

Romberg test. Eyes closed, feet together, arms extended toward the examiner. Includes a gentle push to test the righting reflexes. Careful, don’t let the boxer fall.

General. I would ask a boxer not to participate if he/she has an upper respiratory infection on the upswing, because of the likelihood of being catching.

After an uneventful fight, here’s what I do.

Pupils, extra-ocular muscles, and accommodation. This is time-honored. Press the infraorbital ridges to be sure there is no point-tenderness to suggest a fracture.

Romberg test as above.

Ask a question about the fight to be sure there is no post-traumatic amnesia.

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Worldwide Statistical evidence compiled by Cantu, the comprehensive

longitudinal studies of Bianco and Bucari, and the most recent IOC Injury

Study have demonstrated that Olympic Style Boxing is a safe sport. All but

those philosophically opposed with minds closed to scientific evidence

may celebrate the “Gentleman’s Sport” that is open to young men and

women of every country and race—that has enabled so many young

athletes to improve their lives, their self-image and the living-conditions of

their families.

Charles F. Butler, M.D Ph.D.

Chairman

AIBA Medical Commission 

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 Through knowledge we may combine general physical preparedness (GSP) and sport specific movements to develop the potential of the boxing athlete in a safe and injury free manner.

 In this blog we are targeting those that practice the sport for fun and the more serious boxing athlete whose aim is more competitive.

We shall endeavor to bring to you information about nutrition, treatment & prevention of injuries.

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