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Da Broi M, Al Awadhi A, Voruz P, Nouri A, Schaller K. The spectrum of acute and chronic consequences of neurotrauma in professional and amateur boxing - A call to action is advocated to better understand and prevent this phenomenon. BRAIN & SPINE 2023; 4:102743. [PMID: 38510617 PMCID: PMC10951782 DOI: 10.1016/j.bas.2023.102743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 03/22/2024]
Abstract
Introduction Despite changes in regulations, boxing-related injuries and fatalities are still occurring. The numbers available in the literature regarding mortality and long-term consequences may not accurately represent the actual situation. Indeed, the real extent of this phenomenon remains poorly known. Research question Delineating the spectrum of acute and chronic consequences of boxing-related traumatic brain injuries (TBI). Material and methods Narrative review of the literature concerning acute and chronic boxing-related TBI. Keywords such as mortality, boxing, subdural hematoma were used to search in PubMed and Google scholar. An updated analysis of the Velazquez fatalities collection in boxing was undertaken. Results The Velazquez collection includes 2076 fatalities from 1720 to the present with a death rate of 10 athletes per year. More than half of the deaths (N = 1354, 65.2%) occurred after a knock-out, and nearly 75% happened during professional bouts. In Australia, from 1832 to 2020, 163 fatalities were recorded (75% professional). In Japan, from 1952 to 2016, 38 deaths were recorded with a mean age of 23.9 years. Up to 40% of retired professional boxers in the United States were diagnosed with symptoms of chronic brain injury. Clinical dementia is far more prevalent among professional boxers than in amateurs with an incidence of 20%. Discussion and conclusions A concerted effort to raise awareness and shed light on boxing-related neuro-trauma is required. Similar considerations can be made for other combat sports or contact sports. A call to action to address this knowledge gap, decrease and prevent this phenomenon is advocated.
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Affiliation(s)
- Michele Da Broi
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Abdullah Al Awadhi
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Voruz
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
- Clinical and Experimental Neuropsychology Laboratory, Faculty of Psychology, University of Geneva, Switzerland
| | - Aria Nouri
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Karl Schaller
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
- Department of Neuroscience, University of Geneva, Geneva, Switzerland
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Abstract
Neurologic injuries of both an acute and chronic nature have been reported in the literature for various combat sport styles; however, reports of the incidence and prevalence of these injury types vary greatly. Combat sports clinicians must continue to strive for the development, implementation, and enforcement of uniform minimum requirements for brain safety. These health care providers must also seize on the honor to provide this oft-underserved population with the health care advocacy they very much deserve, but often do not receive.
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Nalepa B, Alexander A, Schodrof S, Bernick C, Pardini J. Fighting to keep a sport safe: toward a structured and sport-specific return to play protocol. PHYSICIAN SPORTSMED 2017; 45:145-150. [PMID: 28152320 DOI: 10.1080/00913847.2017.1288544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Combat sports are growing in popularity, viewership, and participation. The nature of these sports involves repetitive head contact, yet unlike most other professional contact sports, there are no endorsed guidelines or mandates for graduated and systematic return to play following concussion. Here, we review the literature related to concussion and fighting sports, and propose guidelines for concussion management and safe return to play following concussion.
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Affiliation(s)
- Bryce Nalepa
- a Banner Concussion and Sports Medicine Center , Banner University Medical Center-Phoenix , Phoenix , AZ , USA
| | - Amy Alexander
- a Banner Concussion and Sports Medicine Center , Banner University Medical Center-Phoenix , Phoenix , AZ , USA
| | - Sarah Schodrof
- a Banner Concussion and Sports Medicine Center , Banner University Medical Center-Phoenix , Phoenix , AZ , USA
| | - Charles Bernick
- b Lou Ruvo Center for Brain Health, Cleveland Clinic , Las Vegas , NV , USA
| | - Jamie Pardini
- a Banner Concussion and Sports Medicine Center , Banner University Medical Center-Phoenix , Phoenix , AZ , USA
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Stovitz SD, Weseman JD, Hooks MC, Schmidt RJ, Koffel JB, Patricios JS. What Definition Is Used to Describe Second Impact Syndrome in Sports? A Systematic and Critical Review. Curr Sports Med Rep 2017; 16:50-55. [PMID: 28067742 DOI: 10.1249/jsr.0000000000000326] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Concern about what has been termed, "second impact syndrome" (SIS) is a major factor determining return-to-play decisions after concussion. However, definitions of SIS vary. We used Scopus to conduct a systematic review and categorize the definitions used to describe SIS. Of the 91 sources identified, 79 (87%) clearly specified that SIS involved either cerebral edema or death after a concussion when a prior concussion had not resolved. Twelve articles (13%) could be interpreted as merely the events of two consecutive concussions. Among the articles that listed mortality rates, nearly all (33/35, 94%) said the rate of death was "high" (e.g., 50% to 100%). Our review found that most articles define SIS as a syndrome requiring catastrophic brain injury after consecutive concussive episodes. Given that it is unclear how common it is to have a second concussion while not fully recovered from a first concussion, the actual mortality rate of SIS is unknown.
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Affiliation(s)
- Steven D Stovitz
- 1Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN; 3Bio-Medical Library, University of Minnesota, Minneapolis, MN; 4Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; and 5Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Seifert T, Bernick C, Jordan B, Alessi A, Davidson J, Cantu R, Giza C, Goodman M, Benjamin J. Determining brain fitness to fight: Has the time come? PHYSICIAN SPORTSMED 2015; 43:395-402. [PMID: 26295482 DOI: 10.1080/00913847.2015.1081551] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Professional boxing is associated with a risk of chronic neurological injury, with up to 20-50% of former boxers exhibiting symptoms of chronic brain injury. Chronic traumatic brain injury encompasses a spectrum of disorders that are associated with long-term consequences of brain injury and remains the most difficult safety challenge in modern-day boxing. Despite these concerns, traditional guidelines used for return to sport participation after concussion are inconsistently applied in boxing. Furthermore, few athletic commissions require either formal consultation with a neurological specialist (i.e. neurologist, neurosurgeon, or neuropsychologist) or formal neuropsychological testing prior to return to fight. In order to protect the health of boxers and maintain the long-term viability of a sport associated with exposure to repetitive head trauma, we propose a set of specific requirements for brain safety that all state athletic commissions would implement.
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Affiliation(s)
- Tad Seifert
- a 1 Department of Neurology, Norton Healthcare , Louisville, KY, USA.,b 2 Department of Neurology, University of Kentucky , KY, USA.,c 3 Kentucky State Boxing Commission , KY, USA
| | - Charles Bernick
- d 4 Lou Ruvo Center for Brain Health, Cleveland Clinic , Las Vegas, NV, USA
| | - Barry Jordan
- e 5 Department of Neurology, Burke Rehabilitation Hospital , White Plains, NY, USA.,f 6 New York State Athletic Commission , NY, USA
| | - Anthony Alessi
- g 7 Department of Neurology, Backus Hospital , Norwich, CT, USA.,h 8 Department of Neurology, University of Connecticut , CT, USA
| | - Jeff Davidson
- i 9 Department of Emergency Medicine, Valley Hospital , Las Vegas, NV, USA.,j 10 Ultimate Fighting Championship , Las Vegas, NV, USA
| | - Robert Cantu
- k 11 Department of Neurosurgery, Emerson Hospital , MA, USA.,l 12 Sports Legacy Institute , Boston, MA, USA
| | - Christopher Giza
- m 13 Department of Pediatric Neurology, University of California at Los Angeles , CA, USA.,n 14 California State Athletic Commission , CA, USA
| | - Margaret Goodman
- o 15 Headache Center of Southern Nevada , Las Vegas, NV, USA.,p 16 Voluntary Anti-Doping Association , Las Vegas, NV, USA
| | - Johnny Benjamin
- q 17 Department of Orthopedic Surgery, Pro Spine Center , Vero Beach, FL , USA
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Abstract
PURPOSE OF REVIEW Growing public health concern exists over the incidence of chronic traumatic brain injury (TBI) in athletes participating in contact sports. Chronic TBI represents a spectrum of disorders associated with long-term consequences of single or repetitive TBI and includes chronic traumatic encephalopathy (CTE), chronic postconcussion syndrome, and chronic neurocognitive impairment. Neurologists should be familiar with the different types of chronic TBI and their diagnostic criteria. RECENT FINDINGS CTE is the most severe chronic TBI and represents the neurologic consequences of repetitive mild TBI. It is particularly noted among boxers and football players. CTE presents with behavioral, cognitive, and motor symptoms, and can only be definitively diagnosed postmortem. Chronic postconcussion syndrome is defined as postconcussion symptoms that last longer than 1 year and do not appear to resolve; it may develop after a single concussive event. Chronic neurocognitive impairment is an all-encompassing clinical term denoting long-term neurologic sequelae secondary to sports-related trauma and can present either within the postconcussion syndrome or years after a symptom-free interval. SUMMARY This article discusses the diagnostic evaluation of chronic TBI, including clinical history, neurologic examination, neuropsychological testing, neuroimaging, and laboratory testing, as well as the distinctions between CTE, chronic postconcussion syndrome, and chronic neurocognitive impairment. Neurologic impairment among athletes exposed to repetitive brain injury appears to be a real phenomenon. Because CTE has no established treatment, prevention is of paramount importance for athletes participating in contact sports.
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Plassman BL, Grafman J. Traumatic brain injury and late-life dementia. HANDBOOK OF CLINICAL NEUROLOGY 2015; 128:711-22. [DOI: 10.1016/b978-0-444-63521-1.00044-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Zhang YP, Cai J, Shields LBE, Liu N, Xu XM, Shields CB. Traumatic brain injury using mouse models. Transl Stroke Res 2014; 5:454-71. [PMID: 24493632 DOI: 10.1007/s12975-014-0327-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 12/09/2013] [Accepted: 01/05/2014] [Indexed: 12/14/2022]
Abstract
The use of mouse models in traumatic brain injury (TBI) has several advantages compared to other animal models including low cost of breeding, easy maintenance, and innovative technology to create genetically modified strains. Studies using knockout and transgenic mice demonstrating functional gain or loss of molecules provide insight into basic mechanisms of TBI. Mouse models provide powerful tools to screen for putative therapeutic targets in TBI. This article reviews currently available mouse models that replicate several clinical features of TBI such as closed head injuries (CHI), penetrating head injuries, and a combination of both. CHI may be caused by direct trauma creating cerebral concussion or contusion. Sudden acceleration-deceleration injuries of the head without direct trauma may also cause intracranial injury by the transmission of shock waves to the brain. Recapitulation of temporary cavities that are induced by high-velocity penetrating objects in the mouse brain are difficult to produce, but slow brain penetration injuries in mice are reviewed. Synergistic damaging effects on the brain following systemic complications are also described. Advantages and disadvantages of CHI mouse models induced by weight drop, fluid percussion, and controlled cortical impact injuries are compared. Differences in the anatomy, biomechanics, and behavioral evaluations between mice and humans are discussed. Although the use of mouse models for TBI research is promising, further development of these techniques is warranted.
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Affiliation(s)
- Yi Ping Zhang
- Norton Neuroscience Institute, Norton Healthcare, 210 East Gray Street, Suite 1102, Louisville, KY, 40202, USA,
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Bernick C, Banks S. What boxing tells us about repetitive head trauma and the brain. ALZHEIMERS RESEARCH & THERAPY 2013; 5:23. [PMID: 23731821 PMCID: PMC3706825 DOI: 10.1186/alzrt177] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Boxing and other combat sports may serve as a human model to study the effects of repetitive head trauma on brain structure and function. The initial description of what is now known as chronic traumatic encephalopathy (CTE) was reported in boxers in 1928. In the ensuing years, studies examining boxers have described the clinical features of CTE, its relationship to degree of exposure to fighting, and an array of radiologic findings. The field has been hampered by issues related to study design, lack of longitudinal follow-up, and absence of agreed-upon clinical criteria for CTE. A recently launched prospective cohort study of professional fighters, the Professional Fighters Brain Health Study, attempts to overcome some of the problems in studying fighters. Here, we review the cross-sectional results from the first year of the project.
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Affiliation(s)
- Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Avenue, Las Vegas, NV 89106, USA
| | - Sarah Banks
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Avenue, Las Vegas, NV 89106, USA
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Graham M, Myers T, Evans P, Davies B, Cooper S, Bhattacharya K, Grace F, Baker J. Direct Hits to the Head during Amateur Boxing is Associated with a Rise in Serum Biomarkers for Brain Injury. Int J Immunopathol Pharmacol 2011; 24:119-25. [PMID: 21496394 DOI: 10.1177/039463201102400114] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Boxing exposes participants to the physiological response to high intensity exercise and also to direct body and brain trauma. Amateur boxing is increasing and females have also been included in the Olympics. The aim of this study is to assess the stress response and possible brain injury incurred during a match by measuring serum biomarkers associated with stress and cellular brain injury before and after combat. Sixteen male amateur boxers were studied retrospectively. The study population was divided into two groups: (a) a group that received predominantly punches to the head (PTH) and (b) a group that received predominantly punches to the body (PTB). Blood samples were taken before and five minutes after each contest. They were analysed for S-100B, neuron-specific enolase (NSE), creatine kinase (CK) and cortisol. The PTH group received direct contacts to the head (not blocked, parried or avoided) and to the body ( n=8, age: 17.6 ± 5.3, years; height: 1.68 ± 0.13, meters; mass: 65.4 ± 20.3, kg). The PTB group received punches to the body including blocked and parried punches, but received no direct punches to the head, ( n=8, mean ± SD, age: 19.1 ± 3.2 years; height: 1.70 ± 0.75, meters; mass: 68.5 ± 15 kg). Significant increases ( P<0.05) were observed between pre- and post-combat serum concentrations in serum concentrations in PTH of S-100B (0.35 ± 0.61 vs. 0.54 ± 0.73, μg.L−1) NSE (19.7 ± 14 vs.31.1 ± 26.6, ng.ml−1) and cortisol (373 ± 202 vs. 756± 93, nmol.L−1). Significant increases ( P<0.05) of creatine kinase were recorded in both groups. This study demonstrates significant elevations in neurochemical biomarkers in boxers who received direct blows to the head. However, further work is required to quantify this volumetric brain damage and long term clinical sequelae.
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Affiliation(s)
- M.R. Graham
- Sports and Exercise Science, Glyndwr University, Wrexham, Wales, UK
- Newman University College, Birmingham, England
| | - T. Myers
- Newman University College, Birmingham, England
| | - P. Evans
- Royal Gwent Hospital, Newport, Wales
| | | | - S.M. Cooper
- University of Wales Institute, Cardiff, Wales
| | - K. Bhattacharya
- Department of Cardiovascular Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - F.M. Grace
- School of Science, University of the West of Scotland, Hamilton Campus, Almada Street, Hamilton, Scotland, United Kingdom
| | - J.S. Baker
- School of Science, University of the West of Scotland, Hamilton Campus, Almada Street, Hamilton, Scotland, United Kingdom
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