Neurologic injuries in boxing and other combat sports

Headguard use in combat sports: position statement of the Association of Ringside Physicians

Headguard use is appropriate during some combat sports activities where the risks of injury to the face and ears are elevated. Headguards are highly effective in reducing the incidence of facial lacerations in studies of amateur boxers and are just as effective in other striking sports. They should be used in scenarios - especially sparring prior to competitions - where avoidance of laceration and subsequent exposure to potential blood-borne pathogens is important. Headguards are appropriate where avoidance of auricular injury is deemed important; limited data show a marked reduction in incidence of auricular injury in wrestlers wearing headguards.Headguards should not be relied upon to reduce the risk of concussion or other traumatic brain injury. They have not been shown to prevent these types of injuries in combat sports or other sports, and human studies on the effect of headguards on concussive injury are lacking. While biomechanical studies suggest they reduce linear and rotational acceleration of the cranium, changes in athlete behavior to more risk-taking when wearing headguards may offset any risk reduction. In the absence of high-quality studies on headguard use, the Association of Ringside Physicians recommends that further research be conducted to clarify the role of headguards in all combat sports, at all ages of participation. Furthermore, in the absence of data on gender differences, policies should be standardized for men and women.

Effectiveness of Protective Measures and Rules in Reducing the Incidence of Injuries in Combat Sports: A Scoping Review

In recent years, much effort has been made to reduce the injury rate in combat sports. However, the question remains to what extent these measures are effective. Analysis of studies could provide evidence of the effectiveness of measures aimed at reducing the incidence of injuries. This scoping review aims (1) to map research articles dealing with the effectiveness of proper use of protective measures in reducing the incidence of injuries in combat sports; (2) to investigate to what extent the proper use of protective measures and compliance with sports rules help to reduce the incidence of injuries in combat sports; and (3) to identify gaps in the existing literature and suggest future research on this topic. The literature search was conducted on articles published between 2010 and 2023. The main inclusion criteria were studies investigating the effect of sports rules and protective equipment used during training or competition in combat sports on reducing the incidence of injuries. After meeting the criteria, only seven articles from boxing, karate, and taekwondo were included in this study. Results showed that mandatory head guards, along with modern thicker gloves, significantly reduced the rate of knockouts (KOs) and head injuries in boxing despite an increase in the number of head blows. However, the number of facial cuts increased significantly due to the removal of head guards as a piece of mandatory equipment. The use of mouth guards has significantly reduced the number of oral injuries. Changes in rules, such as shortening the duration of bouts, along with the introduction of greater competencies of referees in the supervision of bouts (the standing count, outclassed rule, and medical stops) have helped to reduce the rate of injuries in boxing. The application of a computerised scoring system also contributed to the rate of injuries reduction. The increase in the number of weight divisions had the same effect on U21 karate athletes. However, a higher incentive to attack the head area in taekwondo did not increase the incidence of injuries in youth athletes. It can be concluded that the proper use of protective measures (head and mouth guards) in combination with the rules established for health protection (higher competencies of referees and more weight divisions in competitions) effectively reduces the occurrence of injuries in combat sports. In all Olympic combat sports, the injury incidence should be regularly assessed using the Injury Incidence Rate (IIR) per 1000 min exposures (MEs). Nonetheless, further studies are needed to monitor how established rules (e.g., prohibited behaviour) affect the IIRs.

Sport activities for children and adolescents: the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians 2023-Part 1. Pre-participation physical evaluation in young athletes

The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.

Performance Level and Strike Type during Ground and Pound Determine Impact Characteristics and Net Force Variability

The evaluation of strike impact is important for optimal training, conditioning and tactical use. Therefore, the aim of this study was to evaluate ground and pound strikes, in terms of net force variability, across genders and performance levels. Eighty-one participants, professional men (n = 8, 37 ± 6 years, 195 ± 7 cm, 113 ± 27 kg), advanced men (n = 47, 26 ± 8 years, 180 ± 7 cm, 76 ± 11 kg), and advanced women (n = 26, 21 ± 1 years, 167 ± 6 cm, 61 ± 7 kg) performed three strikes from a kneeling position into a force plate on the ground. The elbow strike resulted in the highest impulse and the palm strike in the highest peak force for all three categories. These results support the recommendation that has previously been made to teach the palm strike to beginners and advanced tactical and combat athletes. The direct punch and elbow strike net force were characterized by a double peak curve, where the first peak variability explained 70.2-84% of the net force. The second peak was pronounced in professional men during elbow strikes, which explained 16% of net force variability. The strike type determines the impact net force and its characteristics, where palm strike is typical by highest peak impact tolerance and elbow strike by double force peak with high net force impulse.

Incidence of Combat Sport-Related Mild Traumatic Brain Injuries Presenting to the Emergency Department From 2012 to 2016

OBJECTIVES

We sought to investigate the incidence and characteristics of traumatic brain injuries [mild traumatic brain injury (MTBI)] presenting to the emergency department as a result of boxing, wrestling, and martial arts (MA).

DESIGN

Retrospective cross-sectional study of MTBI in combat sport athletes who were evaluated in emergency departments in the United States.

SETTING

Patient data were taken from the National Electronic Injury Surveillance System.

PARTICIPANTS

All patients with MTBI from 2012 to 2016, which occurred during participation in boxing, MA, or wrestling.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The incidence of combat sport-related MTBI presenting to emergency departments in the United States.

RESULTS

The mean annual incidence of MTBI due to wrestling was significantly larger (269.3 per 100 000 person-years) than boxing (85.6 per 100 000 person-years) and MA (61.0 per 100 000 person-years) (P < 0.01). The average age at injury was significantly lower for wrestling compared with boxing and MA (15.0 years [SD ± 3.9] vs 21.7 years [SD ± 8.2] vs 19.9 years [SD ± 10.5]; P < 0.01). A significantly larger proportion of MTBIs (95.3%; P < 0.01) in patients younger than 20 years were related to wrestling, compared with boxing (55.8%) and MA (54.1%). Most patients with combat sport-related MTBIs were treated and discharged (96.3%), with only 1.7% of patients being admitted and 0.6% of patients being held for observation.

CONCLUSION

Combat sports athletes are at high risk of sustaining an MTBI. Such athletes presenting to the emergency department for combat sport-related MTBI were more likely to be male and younger than 20 years. Of these athletes, wrestlers experience the highest incidence of MTBI-related emergency department visits.

Martial arts injuries: a longitudinal study about judo, karate and wushu carried out in the Community of Madrid, Spain

BACKGROUND

Martial arts are currently being practiced throughout the world by about 100 million people. Considering that sports injuries account for 20% of all emergencies treated in hospitals, this is an issue that should be further studied. Our objective was to determine the prevalence and type of injuries in wushu, judo, and karate practitioners in Community of Madrid, Spain.

METHODS

A descriptive epidemiology study was carried out. A questionnaire was used to collect data from 457 men and women practicing karate, judo and/or wushu, including injuries from the past five years, type of injury and occurrence during training or competition.

RESULTS

Injuries that disrupted training occurred in 56% of judokas, in 36.7% of karatekas and in 38.9% of wushu practitioners (WP). For judokas, the most common injury site was "shoulder/arm/elbow" (13.43%), for karatekas, it was "lower leg/foot/ankle" (9.95%), and for WP it was "groin/hip/thigh" (9.45%) (P=0.000). The most common injuries in judo and karate were "ankle sprains and joint injuries" (4.98% and 3.98%), while for WP the most common injury were "hamstring strains" (5.47%) (P=0.008). There was no relationship between occurrence of a first injury and sex, age or belt rank.

CONCLUSIONS

Judo is the martial art with the highest percentage of injuries, followed by wushu and then karate.

Evidence of dynamic visual acuity impairment in asymptomatic mixed martial arts fighters

AIM

The purpose of this study was to determine the amount of visual acuity loss with head movement in actively training mixed martial arts (MMA) fighters.

METHODS

Vestibulo-ocular reflex function of 22 asymptomatic, male MMA fighters (age = 29.2 ± 5.1) was assessed by taking the difference between static visual acuity and the dynamic visual acuity test, in both yaw and pitch planes.

RESULTS

The mean static visual acuity testing logMAR was -0.173 (standard deviation [SD] = 0.114). Mean dynamic visual acuity test values decreased with head movement to 0.196 logMAR (SD = 0.103) in yaw; p < 0.001, and to 0.283 logMAR (SD = 0.133) in pitch; p < 0.001.

CONCLUSION

MMA fighters had a decay, beyond normal ranges, in visual acuity during head movement. These decreases may suggest vestibulo-ocular reflex impairment and were unrelated to self-reported concussion history. These results should be cautiously interpreted since there was not a control group.

Prohibiting Headgear for Safety in Amateur Boxing? Opinion of the Canadian Boxing Community: an Online Poll

Background

In 2013, the Amateur International Boxing Association (AIBA) introduced a rule banning headgear for male-senior open class boxers during competition. The AIBA has defended the rule change as motivated by safety and supported by internal unpublished studies. As a result, in 2018, the AIBA plans to universally prohibit headgear in competition: for all competitors (male and female), all ages and all levels. Within Canada, this ruling has generated controversy in the boxing community, yet there has been no overall measure of opinion.

Methods

To address this, we instituted a voluntary, anonymous, online open-access poll to allow members of the boxing community to express their stance on headgear use in competition.

Results

In total, 636 responses were received. A total of 71.5 % of Canadian respondents believed headgear should be mandatory at all levels. Only 5.8 % agreed that headgear should be prohibited, as planned for 2018. Estimating results on a representative breakdown of boxing membership in Canada, a similar pattern emerged, whereby 68.2 % concurred with mandatory headgear while only 4.95 % supported its prohibition. Parents of boxers were almost unanimously against banning headgear, stating they would change sports as a result. Similarly, only 1.7 % of women believed headgear should be prohibited.

Conclusions

The consensus of the Canadian boxing community largely opposes the rule changes that the AIBA has implemented. The results highlight risks posed to the long-term viability of the sport, if significant grassroots safety concerns are disregarded.

Should an increase in cerebral neurochemicals following head kicks in full contact karate influence return to play?

Background:

Cerebral neurochemicals are markers of traumatic brain injury (TBI).

Objectives:

The aim of the study was to determine whether kicks to the head (KTH) in full contact karate significantly increased serum concentrations of protein S-100B, and neurone specific enolase (NSE). Kicks to the body (KTB) were also quantified to asses muscle tissue injury. Muscle damage was assessed by analysis of serum total creatine kinase (CK).

Methods:

Twenty-four full contact karate practitioners were observed and filmed during actual competition and divided into two main groups post event: (1) Kicks to the head and body group (KTH): n = 12; mean ± SD; age, 30.4 ± 6.7 years; height, 1.74 ± 0.1 m; weight, 79.1 ± 2.1 kg; and (2): Kicks to the body group (KTB): n = 12; mean ± SD; age, 28.2 ± 6.5 years; height, 1.75 ± 0.1 m; weight, 79.2 ± 1.7 kg. The KTH group received direct kicks to the head, while group KTB received kicks and punches to the body. Blood samples were taken before and immediately post-combat for analysis of serum S-100B, NSE, CK and cardiac troponin.

Results:

Significant increases in serum concentrations of S-100B (0.12 ± 0.17 vs. 0.37 ± 0.26, µg.L−1) and NSE (11.8 ± 4.1 vs. 20.2 ± 9.1 ng.mL−1) were encountered after combat in the KTH group and CK (123 ± 53 vs. 184 ± 103 U.L−1) in the KTB group (all P <0.05).

Conclusions:

Head kicks in full contact karate cause elevation of neurochemical markers associated with damaged brain tissue. The severity of injury is related to the early post-traumatic release of protein S-100B and NSE. The early kinetics and appearance post injury can reflect intracranial pathology, and suggest S-100B and NSE are extremely sensitive prognostic markers of TBI.

Direct Hits to the Head during Amateur Boxing is Associated with a Rise in Serum Biomarkers for Brain Injury

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.

Boxing-acute complications and late sequelae: from concussion to dementia

BACKGROUND

Boxing has received increased public attention and acceptance in recent years. However, this development has not been accompanied by a critical discussion of the early and late health complications.

METHODS

We selectively review recent studies on the acute, subacute, and chronic neuropsychiatric consequences of boxing.

RESULTS

Cerebral concussions ("knock-outs") are the most relevant acute consequence of boxing. The number of reported cases of death in the ring seems to have mildly decreased. Subacute neuropsychological deficits appear to last longer than subjective symptoms. The associated molecular changes demonstrate neuronal and glial injury correlated with the number and severity of blows to the head (altered total tau, beta-amyloid, neurofilament light protein, glial fibrillary acidic protein, and neuron-specific enolase). The risk of a punch-drunk syndrome (boxer's dementia, dementia pugilistica) as a late effect of chronic traumatic brain injury is associated with the duration of a boxer's career and with his earlier stamina. There are similarities (e.g. increased risk with ApoE4-polymorphism, beta-amyloid pathology) and differences (more tau pathology in boxers) compared with Alzheimer's disease.

CONCLUSION

Protective gear has led to a remarkable reduction of risks in amateur boxing. Similar measures can also be used in professional boxing, but may decrease the thrill, which does appeal to many supporters.