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.
