Tag: boxing

Good versus bad medical stoppages in boxing-stopping a fight in time

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Good versus bad medical stoppages in boxing-stopping a fight in time

 

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

 

 

 

In boxing it is commonly said and not without reason “the fight must go on….”.  Everyone ringside wants the fight to go on-the two boxers and their corners (sometimes not always!), the promoter (always!), the media (always!), the spectators (always!), the Commission and its appointed officials (only if both the boxers meet the Commission requirements for a fair and honestly administered contest), the referee (only if the boxers are fighting a fair fight and able to defend themselves), the judges (usually do not interfere with the conduct of the fight!) and the ringside physicians (only if the boxers are medically fit before, during and immediately after the contest!). So everyone ringside want the fight to go on but do some (media, spectators and promoters) want it more than others? As per the Uniform Boxing Rules (approved August 25, 2001, Amended August 2, 2002, Amended July 3, 2008), the referee is the sole arbiter of a bout and is the only individual authorized to stop a contest. In some states in the United States and in countries around the world both the referee and ringside physician are the sole arbiters of a fight and are the only individuals authorized to enter the fighting area at any time during competition and authorized to stop a fight. The referee and the ringside physician threshold to stop a fight (enough is enough!!!) may vary based on knowledge of boxing rules and regulations, knowledge of the boxers fitness level, pre-existing medical conditions, pre-bout fitness, intra-bout fitness and finally knowledge of medicine and bout ending injuries (head injuries, orthopedic injuries, eye injuries, blunt abdominal trauma). That is the reason why it is the referee (someone who has knowledge of boxing rules and regulations) and the ringside physician (someone who has knowledge of medicine) who are deemed to be the sole arbiters of a bout and entrusted with the health and safety of the boxers. The other MORE important question is when should the fight be stopped on medical grounds? Stopping the bout prematurely is unfair to the boxers, their corners, the promoter and the public. Stopping a bout too late risks serious injury even death of the boxer.

Boxer safety should precede all other considerations. The goal should be to stop the bout before a life threating injury or career ending injury occurs. Key word is before NOT after. Since at times this is not possible so more realistic goal should be timely identification of a serious injury in the ring and timely stoppage of fight. For that to occur the referee and the ringside physician should work as a team complimenting each other’s knowledge. Causes of sudden death in the ring or in the immediate aftermath of a bout are usually neurological.

To help timely identify and prevent TBI in boxing the following good practice guidelines are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:

 

  1. It is a good point to remember that boxers rarely if ever voluntary quit or request the fight to be stopped. They fight for pride, at times at the expense of their health. Corners may also not want the fight to be stopped with the hope that their boxer may turn things around. In a closely contested fight the crowd is excited and wants the fight to go on. At these times, the ringside physician should make the call to stop or let a fighter continue, based solely on the medical condition of the boxer.

 

  1. During the one minute rest period in-between rounds, the ringside physician should step up to the ring canvas for a quick but thorough medical evaluation of the fighter.

 

  1. This is the ideal time for the ringside physician to assess the neurological status of a fighter. In the case of a fighter who suffered a knock down in the preceding round or sustained multiple head shots, the ringside physician should conduct a quick visual evaluation of the fighter (Is the fighter responding appropriately to the commands and directions of his corner? Is he making eye contact with his corner staff? Was the fighter steady on his feet as he walked back to his corner at the end of the round? Does the fighter voice any complaints to his corner staff such as headache or pressure in head, dizziness, and blurred vision?). The ringside physician should attempt to do the above without obstructing or imposing on the corner’s time with its fighter.

 

  1. If the ringside physician determines that he/she needs more time to evaluate the neurological status of a fighter, he/she should communicate this to the referee. The referee after starting the bout shall call a time out and walk the fighter to the ringside physician to be examined. The referee directs the other fighter to remain in the neutral corner. The ringside physician’s goal at this time is to conduct a quick but thorough neurological assessment of the fighter. He/she should begin this by asking the fighter few leading questions such as-how do you feel? Does your head hurt? Do you know where you are? If the fighter appears confused and disoriented, the ringside physician may ask more question like which round is it? Who is your opponent? Where are you fighting (name of the venue)? The ringside physician should then look for pupil symmetry and response and assess extra ocular movements (have the fighter track finger from side to side). The ringside physician should give the fighter a complex command such as touch your left ear with right glove and should assess the fighter’s gait and balance at the same time (is the fighter steady on his/her feet or is he leaning on the ropes for support). The ringside physician should then communicate to the referee whether the fighter can continue or the fight should be stopped. The whole process should not take more than 10 seconds.

 

  1. The ringside physician should be aware that too much time spent evaluating the fighter during time out, inadvertently gives the fighter more time to recover. The opponent’s corner rightfully resents this and it is akin to getting “saved by the bell”. The public, TV audience, press and TV announcers question the fairness of the Commission’s administration of the contest and the credibility and impartiality of the bout officials-e.g., referees, judges and ringside physicians.

 

  1. If serious health concern is raised for a fighter and the ringside physician is unable to document a good exam to determine whether it is safe for the fighter to continue, consideration should be given to stopping the fight. In these circumstances the ringside physician should tell the referee that the fight be stopped on medical grounds.

 

  1. For ringside physicians with limited ringside experience, it is encouraged that they consult with other ringside physicians at the venue and the chief medical officer before deciding to stop a fight on medical grounds.

 

 

 

 

 

 

 

 

As injuries mount, the boxing community is looking within and the sport is under scrutiny from the medical community and media. Boxing is the most controversial sport for physicians and neurologists in particular because of the potential risk and degree of neurologic injury, questions and concerns about long-term sequelae (chronic traumatic encephalopathy), and the occurrence of deaths in the ring  . Various medical associations including the American Medical Association and the American Academy of Pediatrics have stated opposition to both amateur and professional boxing . Many have called to ban boxing altogether . Dr. Hauser in a recent editorial titled “Beaten into action: a perspective on blood sports” says that “the medical, and especially the neurology, community has an obligation to do more. We need to spread the word that brain bashing is not a socially acceptable spectator sport, and partner with our national organizations to expand and improve the effectiveness of public awareness and other educational initiatives.” He further goes on to state “we should forcefully counter articles in the medical literature taking the position that closer medical supervision could obviate the need for a ban, or even worse that consenting adults have the ethical right to maim each other if they choose to do so .” While the neurological risks of boxing cannot be completely eliminated, boxing can be made safer .

 

 

 

Conclusion

 

 

It is recommended that the above proposed best practice guidelines be debated vigorously by the ringside physician and large scientific community and evidence based guidelines on medical stoppages be developed by the medical community in conjunction with professional boxing governing bodies. Boxing can be made safer but it shall be foolhardy to forget that frequently there is a very fine line between a good medical stoppage (medical stoppage done at the right time during the bout and for the right indication) versus a bad medical stoppage (medical stoppage done either too late, too prematurely or for the wrong indication). It is far better to stop a fight early rather than late. A ringside physician should never forget that in boxing one punch can change everything. One punch can kill!


 

Making Boxing Safer

braindiseases3 Comments

Boxing as a sport is close to my heart. Boxing is also a sport with a high risk for traumatic brain injuries. Ringside physicians are entrusted with the health and safety of boxers and combatants of other contact sports such as MMA. The health and safety of boxers is something I am passionate about.

boxer-safety-final-edited

The Powerpoint presentation reflects some of my thoughts on how boxing can be made safer primarily targeted at referees. It talks about the importance of constant communication between ringside physicians and referees. The views and opinions expressed are entirely my own. They do not reflect the views of the New York State Athletic Commission or any other boxing governing body. I disclose that I work for the New York State Athletic Commission as a ringside physician.

 

Nitin K Sethi, MD

Chronic traumatic encephalopathy-making the games we play safer

braindiseases2 Comments

New data indicates the ever present danger of chronic traumatic encephalopathy (CTE) in contact sports such as boxing, mixed martial arts (MMA), football, ice-hockey and even soccer.  Contrary to popular belief it is now felt that it is just not concussive injuries but even sub-concussive injuries which can predispose an athlete to CTE. This may be of importance to a soccer player who repeatedly heads the ball during play. There are other questions for which we still do not have a good answer.

1. How many concussions are needed and how severe they need to be for CTE to develop? Is there a limit beyond which the brain loses its capacity to compensate for chronic trauma and signs and symptoms of CTE appear? If so what is this limit? Can it be defined? If a player stops playing before this limit is reached would CTE be aborted?

2. Once CTE develops can it be reversed?

3. Is there a way to protect the brain from developing CTE apart from changing the way the games are played. Changing the rules of the game (such as avoiding head butts during football, heading the ball in soccer, direct blows to the head in MMA, wearing safety gear/helmets) shall certainly help but are there other neuroprotective strategies such as medicines (antioxidants, anti-inflammatory drugs) which can be given to prevent the onset and progression of CTE?

As you can see there are many questions for which we still lack good answers. Making the games we play safer certainly sounds a logical principle and hence the thrust to identify concussions in a timely fashion on the playing field and rest the player till complete recovery is documented. Neurologists, neurosurgeons and other physicians skilled in neurosciences by virtue of their training are better equipped to identify concussions and thus there is a growing call to have them by the side of the playing field in every professional and now even college level game. Biomakers and imaging markers to identify CTE in the living brain are also been explored.

Till more is known about CTE and more importantly on how to prevent and reverse it, making the games we love and play safer should be the goal.

 

Nitin K Sethi, MD

Head injuries sustained while playing contact sports such as boxing, ice-hockey and football—how concerned should we be about chronic traumatic encephalopathy?-A neurologist’s viewpoint

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Head injuries sustained while playing contact sports such as boxing, ice-hockey and football—how concerned should we be about chronic traumatic encephalopathy?-A neurologist’s viewpoint

Nitin K Sethi

 

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

Address for correspondence:

Nitin K. Sethi, MD

ComprehensiveEpilepsyCenter

New York-Presbyterian Hospital

WeillCornellMedicalCenter

525 East, 68th Street

New York, NY10065

Tel: + 212-746-2346

Fax: + 212-746-8845

 

 

The problem

Head injuries frequently occur while playing contact sports such as boxing, ice-hockey, American football, mixed martial arts (MMA) and even soccer. In sports such as boxing and MMA the goal is to knock out your opponent by causing a concussion. The perils of boxing are thus well recognized by the medical community especially by neurologists.  Boxer’s encephalopathy, punch-drunk syndrome and dementia pugilistica are terms used to describe the neurodegenerative changes seen in professional boxers as well as athletes in other contact sports who suffer repeated concussions during their professional careers. There is now increasing evidence that repeated concussions sustained by a boxer or an athlete in his or her professional career predisposes them to memory problems later on in life (says in their 40’s and 50’s) and Alzheimer’s disease (dementia) like pathological changes are visible in the brain on histopathology. These athletes are also plagued by neuropsychiatric disorders such as anxiety and depression in their later years. Parkinsonian features (problems with gait and balance) may appear later in life due to damage to the deep grey nuclei of the brain.

My own love for boxing

With this increased awareness about the perils of repeated concussions there is a thrust to make these sports safer. But can boxing, MMA and American football be made safer? It is ironic that I was personally drawn to boxing near about the time I started my neurology residency in Saint Vincent’s Hospital and Medical Center in New York.  Prior to that I knew little if anything about this sport. I had just joined a new gym and happened to walk into a boxing class. I was standing outside peeping in when Tyrone the boxing coach yelled out at me across the room. The first class is free come in he said. There and then my love for boxing was born. Since that fateful day 7 years ago, I have grown to love this sport. I have been boxing on and off since then, yes at times I spar usually with boxers who I know won’t throw a wild punch. For one to really understand this sport and the men and women behind it, one needs to spend time in a boxing gym. New York can boast of some world famous boxing gyms such as Gleason’s gym, I call Mendez boxing on 26th Street and 6th Avenue home. There I am known simply as doc. I see the passion and discipline in the men and women who train there especially the ones who are fighting on the amateur and professional circuits. Most of them are in the age range of 16-25. During my time at Mendez I have had the opportunity to closely observe how these men and women train and I tell you it is grueling. Most start with jumping rope for about 10-15 minutes. Then shadow boxing, a few rounds on the heavy bag and pad work. Then come the sparring sessions which can be highly entertaining to watch.  Most boxers end their work-out by going a few rounds on the speed bag. I can honestly say that boxing has changed me for the better; both in mind and in body. So I recently applied and got accepted to be a panel physician for the New York Athletic (boxing) Commission. I feel this shall accord be a unique opportunity to closely observe professional boxing from a neurologist’s point of view.

Making boxing and football safer

So how can we make boxing and other contact sports safer? Some say the best way is to change the rules that govern these sports. In the case of American football one option would be to limit aggressive and hard tackles that encourage helmet to helmet collisions. There has been a healthy debate on this subject. Some have advised better quality helmets the kind worn by soldiers in the battlefield to prevent traumatic brain injury (TBI). The new military helmets (advanced combat helmets) are especially designed to prevent TBI following an improvised explosive device detonation though it is still debatable whether the helmets actually do achieve this objective. The players helmets can be further fitted with a sensor which records the force of impact. This data can then be readily accessed by a physician on the sideline and a timely decision can be made to either pull a player out of play or allow him to continue after a concussion. We certainly have the technology to do this at present but do we know how to analyze the data? Like for example how much should the concussive force be to warrant pulling a player out of a critical game? Some advocate that the rules be amended more drastically such as a complete ban on head to head collisions be enforced. Players should be taught to tackle leading with their shoulder and not using their head as a battering ram. Or that helmets be taken away completely so that players and coaches are forced to switch to “safer” tactics. The main problem with some of these rather novel ideas is that you risk changing the very nature of the sport and driving away the fans. Coming back to boxing you all would agree that most of us go to a boxing match to see a hard knockout. Any Iron Mike fan shall testify to that! Boxing would not be boxing if the rules were amended so that blows to the head were not allowed and professional boxers were forced to wear protective head gear.  So when it comes to boxing and MMA a more “practical” solution would be to enhance our ability to detect concussions in a more comprehensive and timely fashion. But this itself is no easy task. Anyone can identify a concussion when the boxer is knocked out and suffers prolonged loss of consciousness (>5 minutes). Over and out! However it is the minor/subtle concussions which are harder to detect. At present this is what happens. A boxer goes down and a ring side physician like me jumps into the ring to assess him. Are you Okay? Do you want to go on? Raise your gloves for me. Track my finger with your eyes. If he is able to answer my questions and follow my commands, I clear him to fight further. Studies though show that many concussions are missed if examined in this rudimentary fashion. Grossly the boxer looks fine but he is not. There are a few well documented cases where in the boxer has gone on to fight after sustaining a concussion and even win the fight only to be found dead in his bed the next day (second impact syndrome). So is there any better way to identify concussions in a timely fashion?

The Kind Devick test (www.kingdevicktest.com) has been found to be quite sensitive in identifying concussions. It basically involves the testee reading a set of numbers off a card. The number of errors and time taken to accomplish this task is recorded and can be used to assess if a concussion has occurred. This test can be administered to boxers and other athletes prior to the fight or game and these scores serve as the baseline scores. If the boxer gets hit during the fight or a football player suffers a concussion on the field, the test can be administered on the sidelines and a decision to either pull the player/boxer or to let him continue can be made. The Kind Devick test has some inherent advantages. It is easy to administer by anyone (not just a physician), the test can be administered through hand held cards or on the Ipad, quick to administer (this is very helpful when it comes to boxing since the decision to stop or continue the fight has to be made in a matter of minutes), finally it can be administered ringside or on the sidelines.

Other ways to make boxing, American football and MMA safer include yearly neuropsychological testing of all participants to identify deficits in memory, cognition and other neuropsychiatric morbidities such as anxiety and depression. Serial  MRI scans of the brain should be carried out during the athletes career and a physician trained in the neurosciences such as a neurologist or neurosurgeon should be present ringside in all professional and amateur fights/ games (I agree this is not a very practical solution).

Final thoughts

Finally knowledge is power and all athletes, their coaches, parents of children who indulge in contact sports should be made aware of the perils of repeated concussions, how to identify and avoid them. Working together we can certainly making boxing and American football safer.

Chronic traumatic encephalopathy/ boxers encephalopathy/ dementia pugilistica

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Chronic traumatic encephalopathy

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY

I recently read an article dealing with chronic traumatic encephalopathy (CTE) and the pledge by some professional football players to donate their brains for the study of CTE. As everything to do with brain health fascinates me, I decided this might be a good time to share my thoughts about CTE with my readers.

So what exactly is CTE? In simple terms it means encephalopathy (brain damage) caused by chronic trauma. Professional athletes especially those playing contact sports like American football, rugby, boxing and wrestling are prone to repeated head trauma. Have any of you ever watched a UFC fight? They are brutal, though as a spectator, I have to admit I love them and find them quite entertaining. Matt Hughes is my hero and I marvel at his strength and skills. But this entertainment comes at a price, at least for the athlete involved. A boxer during his professional career gets hit on his head countless times. Even though he may never get knocked out (have a concussion), the repeated blows to the head do take a toll. Studies have shown these players get small microbleeds in the deeper parts of the brain such as the basal ganglia. Over years this microdamage to the brain accumulates and these players complain of memory and other cognitive problems. They may further develop symptoms suggestive of Parkinsonism and Alzheimer’s disease. They have headache and also complain of balance problems (this was labeled in the past as “punch-drunk syndrome“). The dementia seen in patients with CTE has histopathological features similar to those seen in Alzheimer’s dementia (hence the term “dementia pugilistica“).

So how do you prevent yourself from CTE?  Simple, avoid contact sports especially if you are not doing it for professional reasons. Concussions do hurt the brain and contrary to common belief may cause permanent structural damage to the brain. If you suffer a concussion while playing in school or college do not return to play till you feel completely better and have a doctor’s clearence (read my post on concussions and return to play decision at http://braindiseases.info). Give your brain time to heal and drink alcohol in moderation (remember alcohol is a neurotoxin and too much is bad for the brain). If like me you indulge in contact sports like boxing, always always do wear protective head gear when you fight.

“YOUR BRAIN IS YOUR BEST FRIEND, DO NOT HURT HIM FOR WHOMSOEVER OR WHATSOEVER”

 

Concussion during sports and return to play decisions

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                                      Concussion during sports and return to play decisions

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

I recently read an article in the Archives of Neurology ( Vol 65, Sep 2008) by Dr. Lester Mayers about return to play (RTP) criteria after athletic concussion. As concussions are relatively common sport related injuries (especially in contact sports like football, rugby and boxing) I thought it would be a good idea to review some of the salient points of the article in this forum.

Concussion is a common type of traumatic brain injury and has been referred to by other names such as mild traumatic brain injury, mild head injury and minor head trauma. No good defination for concussion exists though it is frequently described as head injury with transient loss of brain function (usually a short period of loss of consciousness occurs).

Let me explain with the help of an example. I love to box (true one of the few neurologist who actually likes boxing). Lets assume I am going a couple of rounds in the ring with another guy.  A southpaw with a mean right hand. First round here we go!!!. I got my right and left combinations going. Hmmm feeling good and then it happens. I walk into his right. BOOOOOM!!! My knees give in and I hit the canvas. I see stars shining and birds twittering. The referee is asking me “Are you okay? Are you okay?” I look dazed and then slowly come around and answer I am fine. I am helped out of the ring, the fight is over!!! THERE I JUST HAD MY FIRST CONCUSSION!!!

Can I return to play/ box after a 10 mins break?

 Or rather should I return to play after a break?

Is it safe?

 Am I okay?

All these questions are addressed by Dr. Mayers in his review. Traditionally return to play decisions are made by the field side by the team physician or in the case of boxing by the doctor at the ringside. This is usually a clinical judgement with doctors relying on the documentation of resolution of symptoms at rest and during exertion to provide an estimate of the appropiate time for the athletes to resume practice and play (return to play).

A stepwise process was outlined by the Canadian Academy of Sports Medicine:

Step 1: no activity, no play and complete rest till asymptomatic and with a normal neurological examination–if your clear this then Step 2: light aerobic exercise permitted, no resistance training–if you clear this then Step 3: can return to sports specific training and resistance training—if patient remains asymptomatic then can be cleared for Step 4: non-contact training can begin–if patient remains asymptomatic then he is cleared for Step 5: full contact training —if he still remains asymptomatic then he is cleared for Step 6-full play!!! (As you can imagine these criteria are for professional atheletes but also apply for others)

As you can see there are steps to be followed before return to play can be allowed. If you fail one step you go back to the previous step and remain there till you feel better and are ready to proceed further.

Why is this important? Studies have shown that even simple concussions cause cerebral dysfunction (reflecting damage to the brain at the celluar level) and that it takes a minimum of 4 weeks for the brain to revert back to normal. If RTP occurs earlier, the athlete is at risk for a recurrent concussion and further brain damage. Even death can occur (we have all heard of boxers who die during or shortly after a bout).

Learning points from Dr. Mayers review:

1) Concussions are common.

2) Concussions can be serious and even fatal.

3) Concussions lead to cerebral dysfunction and damage to the brain at the cellular level.

4) Return to play decision should be made by a doctor skilled in this task.  A postconcussion RTP interval of at least 4 weeks is imperative (Dr. Mayers takes pain to point out that even more time may be needed to permit complete brain healing and recovery).

My advise to you:

1) Treat a concussion with respect and see a doctor if you suffer one.

2) You may feel you are okay but you are not. The brain takes time to heal completely from a concussion.

3) Do not return to play. See a doctor and get his advise. Let him decide what the return to play interval should be.