Problems in health management of professional boxers in Japan

Adverse Health and Psychosocial Repercussions in Retirees from Sports Involving Head Trauma: Looking at the Sport of Boxing

Academic scholarship has steadily reported unfavourable clinical findings on the sport of boxing, and national medical bodies have issued calls for restrictions on the sport. Yet, the positions taken on boxing by medical bodies have been subject to serious discussions. Beyond the medical and legal writings, there is also literature referring to the social and cultural features of boxing as ethically significant. However, what is missing in the bioethical literature is an understanding of the boxers themselves. This is apart from their brain injuries, the debates about the degenerative brain disease known as chronic traumatic encephalopathy (CTE), and related issues about the disease. This article argues that the lives of boxers, their relationships, their careers, and their futures, also requires its own research, particularly in telling stories about their lives, and those lives and futures which boxing affects. The article uses two approaches. First, to imagine a more enduring “whole of life viewpoint” by using an extended future timeframe. Second, to consider perspectives of a person’s significant others. After reviewing the boxing literature, the article discusses social settings and then explores the hidden social relationships in life after boxing. With these longer time and close relationship viewpoints, three important themes emerge: family and kinship; age, stage and career; and the effects of boxing fatalities. These analyses are used in conjunction with relevant clinical findings which complement the telling of stories to improve medical information, and engages professional and public empathy for people’s experience of illness and difficulties in coping.

Antibodies against the pituitary and hypothalamus in boxers

Traumatic brain injury (TBI), a growing public health problem worldwide, has recently been recognized as one of the leading causes of hypopituitarism. The main causes of TBI-induced pituitary dysfunction are car accidents, falls, violence, sports-related brain injury, and war accidents, including blast-related brain injuries. Car accidents and falls are the most common causes of TBI and pituitary dysfunction among the younger generation and elderly population, respectively. The prevalence of hypopituitarism after TBI is about 30%. GH is the most common hormone lost. The mechanisms underlying hypopituitarism are still unclear; however, recent studies have demonstrated that hypoxic insult, increased intracranial pressure, axonal injury, genetic predisposition, neuroinflammation, and autoimmunity may be responsible for the development of pituitary dysfunction. Neuroendocrine abnormalities are recently described in athletes dealing with contact sports, including boxing and kickboxing, which are characterized by chronic repetitive head trauma. Mild TBI and concussion are accepted in boxing and kickboxing. The positivity of antipituitary and antihypothalamic antibodies is also a significant risk factor in the development of neuroendocrine abnormalities. Autoimmune reaction may also be responsible for the reduction in pituitary volume in boxers with hypopituitarism. In this chapter, the role of autoimmunity in the occurrence of pituitary dysfunction among boxers is discussed.

Vagus nerve stimulation paired with tones for tinnitus suppression: Effects on voice and hearing

OBJECTIVE

In individuals with chronic tinnitus, our interest was to determine whether daily low-level electrical stimulation of the vagus nerve paired with tones (paired-VNSt) for tinnitus suppression had any adverse effects on motor-speech production and physiological acoustics of sustained vowels. Similarly, we were also interested in evaluating for changes in pure-tone thresholds, word-recognition performance, and minimum-masking levels. Both voice and hearing functions were measured repeatedly over a period of 1 year.

STUDY DESIGN

Longitudinal with repeated-measures.

METHODS

Digitized samples of sustained frontal, midline, and back vowels (/e/, /o/, /ah/) were analyzed with computer software to quantify the degree of jitter, shimmer, and harmonic-to-noise ratio contained in these waveforms. Pure-tone thresholds, monosyllabic word-recognition performance, and MMLs were also evaluated for VNS alterations. Linear-regression analysis was the benchmark statistic used to document change over time in voice and hearing status from a baseline condition.

RESULTS

Most of the regression functions for the vocal samples and audiometric variables had slope values that were not significantly different from zero. Four of the nine vocal functions showed a significant improvement over time, whereas three of the pure tone regression functions at 2-4 kHz showed some degree of decline; all changes observed were for the left ear, all were at adjacent frequencies, and all were ipsilateral to the side of VNS. However, mean pure-tone threshold changes did not exceed 4.29 dB from baseline and therefore, would not be considered clinically significant. In some individuals, larger threshold shifts were observed. No significant regression/slope effects were observed for word-recognition or MMLs.

CONCLUSION

Quantitative voice analysis and assessment of audiometric variables showed minimal if any evidence of adverse effects using paired-VNSt over a treatment period of 1 year. Therefore, we conclude that paired-VNSt is a safe tool for tinnitus abatement in humans without significant side effects.

LEVEL OF EVIDENCE

Level IV.

Boxing fatalities in relation to rule changes in Japan: secondary data analysis

OBJECTIVES

To examine whether changing weigh-in from the same day of the match to the day before the match and prohibiting 6-oz gloves are associated with fatalities in boxing matches sanctioned by the Japan Boxing Commission (JBC).

METHODS

We analyzed the rates of boxing fatalities before and after the two rule changes above via secondary analysis of data. Demographics and boxing records of deceased boxers were examined using descriptive statistics, exact binomial test the Mann-Whitney-Wilcoxon test and Fisher's exact tests.

RESULTS

As of this study, a total of 38 boxers (23.9 ± 3.3 years of age) reportedly died due to injuries sustained in JBC-sanctioned boxing matches since 1952. Changing weigh-in to the day before the match or prohibiting 6-oz gloves was not significantly associated with the rates of boxing fatalities 5 years and 10 years before and after the rule changes (p > 0.05). Deceased boxers after these rule changes were significantly older, completed significantly more rounds in the final match, and were significantly less likely to lose the previous match (prior to the final match) and to do so by knockouts (p < 0.05).

CONCLUSION

Changing weigh-in to the day before the match and prohibiting 6-oz gloves may not result in reducing boxing fatalities.

GH and Pituitary Hormone Alterations After Traumatic Brain Injury

Traumatic brain injury (TBI) is a crucially important public health problem around the world, which gives rise to increased mortality and is the leading cause of physical and psychological disability in young adults, in particular. Pituitary dysfunction due to TBI was first described 95 years ago. However, until recently, only a few papers have been published in the literature and for this reason, TBI-induced hypopituitarism has been neglected for a long time. Recent studies have revealed that TBI is one of the leading causes of hypopituitarism. TBI which causes hypopituitarism may be characterized by a single head injury such as from a traffic accident or by chronic repetitive head trauma as seen in combative sports including boxing, kickboxing, and football. Vascular damage, hypoxic insult, direct trauma, genetic predisposition, autoimmunity, and neuroinflammatory changes may have a role in the development of hypopituitarism after TBI. Because of the exceptional structure of the hypothalamo-pituitary vasculature and the special anatomic location of anterior pituitary cells, GH is the most commonly lost hormone after TBI, and the frequency of isolated GHD is considerably high. TBI-induced pituitary dysfunction remains undiagnosed and therefore untreated in most patients because of the nonspecific and subtle clinical manifestations of hypopituitarism. Treatment of TBI-induced hypopituitarism depends on the deficient anterior pituitary hormones. GH replacement therapy has some beneficial effects on metabolic parameters and neurocognitive dysfunction. Patients with TBI without neuroendocrine changes and those with TBI-induced hypopituitarism share the same clinical manifestations, such as attention deficits, impulsion impairment, depression, sleep abnormalities, and cognitive disorders. For this reason, TBI-induced hypopituitarism may be neglected in TBI victims and it would be expected that underlying hypopituitarism would aggravate the clinical picture of TBI itself. Therefore, the diagnosis and treatment of unrecognized hypopituitarism due to TBI are very important not only to decrease morbidity and mortality due to hypopituitarism but also to alleviate the chronic sequelae caused by TBI.

Pituitary dysfunction after traumatic brain injury: a clinical and pathophysiological approach

Traumatic brain injury (TBI) is a growing public health problem worldwide and is a leading cause of death and disability. The causes of TBI include motor vehicle accidents, which are the most common cause, falls, acts of violence, sports-related head traumas, and war accidents including blast-related brain injuries. Recently, pituitary dysfunction has also been described in boxers and kickboxers. Neuroendocrine dysfunction due to TBI was described for the first time in 1918. Only case reports and small case series were reported until 2000, but since then pituitary function in TBI victims has been investigated in more detail. The frequency of hypopituitarism after TBI varies widely among different studies (15-50% of the patients with TBI in most studies). The estimates of persistent hypopituitarism decrease to 12% if repeated testing is applied. GH is the most common hormone lost after TBI, followed by ACTH, gonadotropins (FSH and LH), and TSH. The underlying mechanisms responsible for pituitary dysfunction after TBI are not entirely clear; however, recent studies have shown that genetic predisposition and autoimmunity may have a role. Hypopituitarism after TBI may have a negative impact on the pace or degree of functional recovery and cognition. What is not clear is whether treatment of hypopituitarism has a beneficial effect on specific function. In this review, the current data related to anterior pituitary dysfunction after TBI in adult patients are updated, and guidelines for the diagnosis, follow-up strategies, and therapeutic approaches are reported.

Neurological consequences of traumatic brain injuries in sports

Traumatic brain injury (TBI) is common in boxing and other contact sports. The long term irreversible and progressive aftermath of TBI in boxers depicted as punch drunk syndrome was described almost a century ago and is now widely referred as chronic traumatic encephalopathy (CTE). The short term sequelae of acute brain injury including subdural haematoma and catastrophic brain injury may lead to death, whereas mild TBI, or concussion, causes functional disturbance and axonal injury rather than gross structural brain damage. Following concussion, symptoms such as dizziness, nausea, reduced attention, amnesia and headache tend to develop acutely but usually resolve within a week or two. Severe concussion can also lead to loss of consciousness. Despite the transient nature of the clinical symptoms, functional neuroimaging, electrophysiological, neuropsychological and neurochemical assessments indicate that the disturbance of concussion takes over a month to return to baseline and neuropathological evaluation shows that concussion-induced axonopathy may persist for years. The developing brains in children and adolescents are more susceptible to concussion than adult brain. The mechanism by which acute TBI may lead to the neurodegenerative process of CTE associated with tau hyperphosphorylation and the development of neurofibrillary tangles (NFTs) remains speculative. Focal tau-positive NFTs and neurites in close proximity to focal axonal injury and foci of microhaemorrhage and the predilection of CTE-tau pathology for perivascular and subcortical regions suggest that acute TBI-related axonal injury, loss of microvascular integrity, breach of the blood brain barrier, resulting inflammatory cascade and microglia and astrocyte activation are likely to be the basis of the mechanistic link of TBI and CTE. This article provides an overview of the acute and long-term neurological consequences of TBI in sports. Clinical, neuropathological and the possible pathophysiological mechanisms are discussed. This article is part of a Special Issue entitled 'Traumatic Brain Injury'.

Precursors of post-bout motion sickness in adolescent female boxers

Athletic head trauma (both concussive and sub-concussive) is common among adolescents. Head trauma often is followed by motion sickness-like symptoms, by changes in cognitive performance, and by changes in standing body sway. We evaluated adolescent female boxers who did and did not report motion sickness after a bout (i.e., a boxing match), together with a control group of non-boxers. We asked whether pre-bout body sway would differ between boxers who experienced post-bout motion sickness and those who did not. In addition, we asked whether pre-bout cognitive performance would differ between non-boxers and boxers with and without post-bout motion sickness. Seven of twenty boxers reported motion sickness after a bout. Pre-bout measures of cognitive performance and body sway were different in boxers who reported post-bout motion sickness than in boxers without post-bout sickness or controls. The results suggest that susceptibility to motion sickness-like symptoms in adolescent female boxers may be manifested in characteristic patterns of body sway and cognitive performance. It may be possible to use pre-bout data to predict susceptibility to post-bout symptoms.

Cognitive and postural precursors of motion sickness in adolescent boxers

Athletic head trauma (both concussive and sub-concussive) is common among adolescents. Concussion typically is followed by motion sickness-like symptoms, by changes in cognitive performance, and by changes in standing body sway. We asked whether pre-bout body sway would differ between adolescent boxers who experienced post-bout motion sickness and those who did not. In addition, we asked whether pre-bout cognitive performance would differ as a function of adolescent boxers' post-bout motion sickness. Nine of nineteen adolescent boxers reported motion sickness after a bout. Pre-bout measures of cognitive performance and body sway differed between boxers who reported post-bout motion sickness and those who did not. The results suggest that susceptibility to motion sickness-like symptoms in adolescent boxers may be manifested in characteristic patterns of body sway and cognitive performance. It may be possible to use pre-bout data to predict susceptibility to post-bout symptoms.

The neuropathology and neurobiology of traumatic brain injury

The acute and long-term consequences of traumatic brain injury (TBI) have received increased attention in recent years. In this Review, we discuss the neuropathology and neural mechanisms associated with TBI, drawing on findings from sports-induced TBI in athletes, in whom acute TBI damages axons and elicits both regenerative and degenerative tissue responses in the brain and in whom repeated concussions may initiate a long-term neurodegenerative process called dementia pugilistica or chronic traumatic encephalopathy (CTE). We also consider how the neuropathology and neurobiology of CTE in many ways resembles other neurodegenerative illnesses such as Alzheimer's disease, particularly with respect to mismetabolism and aggregation of tau, β-amyloid, and TDP-43. Finally, we explore how translational research in animal models of acceleration/deceleration types of injury relevant for concussion together with clinical studies employing imaging and biochemical markers may further elucidate the neurobiology of TBI and CTE.

From Concussion to Chronic Traumatic Encephalopathy: A Review

Sports-related activities account for an estimated 10% of head and spinal cord injuries. In recent years, concussion in particular has garnered more interest in the medical field as well as the media. Reports of athletes suffering from long-term cognitive deficits and Parkinsonian symptoms have sparked concern in a disease process that has often been underestimated or ignored. As more reports surface, the desperate need for a better understanding of the neuropathology has been made clear. In addition to the concern for acute injury, long-term sequelae such as chronic traumatic encephalopathy (CTE) are feared consequences of concussive injuries. Research studies have shown significant overlap in the neuropathology between CTE and chronic neurodegenerative processes such as Alzheimer’s disease (AD). In particular, tau protein deposition has been found to be present in both disease processes and may play an important part in the clinical findings observed. The present review discusses concussion and our current understanding of pathological findings that may underlie the clinical features associated with concussive injuries and resulting chronic traumatic encephalopathy.

Pre-bout standing body sway differs between adult boxers who do and do not report post-bout motion sickness

Background

Motion sickness is characterized by subjective symptoms that include dizziness and nausea. Studies have shown that subjective symptoms of motion sickness are preceded by differences in standing body sway between those who experience the symptoms and those who are not. Boxers often report dizziness and nausea immediately after bouts. We predicted that pre-bout standing body sway would differ between boxers who experienced post-bout motion sickness and those who did not.

Methodology/Principal Findings

We collected data on standing body sway before bouts. During measurement of body sway participants performed two visual tasks. In addition, we varied stance width (the distance between the heels). Postural testing was conducted separately before and after participants' regular warm-up routines. After bouts, we collected self-reports of motion sickness incidence and symptoms. Results revealed that standing body sway was greater after warm-up than before warm-up, and that wider stance width was associated with reduced sway. Eight of 15 amateur boxers reported motion sickness after a bout. Two statistically significant interactions revealed that standing body sway before bouts differed between participants who reported post-bout motion sickness and those who did not.

Conclusions/Significance

The results suggest that susceptibility to motion sickness in boxers may be manifested in characteristic patterns of body sway. It may be possible to use pre-bout data on postural sway to predict susceptibility to post-bout motion sickness.

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.

Pituitary function in subjects with mild traumatic brain injury: a review of literature and proposal of a screening strategy

Traumatic brain injury (TBI) is an important public health problem all over the world. The level of consciousness of the patients and the severity of the brain injury is commonly evaluated by the Glascow Coma Scale as mild, moderate and severe TBI. When we consider the high frequency of mild TBI (MTBI) among the all TBI patients the burden of the pituitary dysfunction problem in this group could not be ignored. However, one of the most important and still unresolved questions is which patients with MTBI should be screened for hypopituitarism? Another type of head trauma which could be considered as the subgroup of MTBI is sports related chronic repetitive head trauma. Therefore, in this review we will discuss the frequency, characteristics and current management of pituitary dysfunction in patients with MTBI including the subjects exposed to sports related chronic mild head trauma.

Head Trauma in Female Professional Wrestlers

The clinical characteristics of head trauma were evaluated in 18 wrestlers belonging to a female professional wrestling organization, 13 regular members and five trainees aged 15-34 years. Medical examinations for head trauma were performed in all wrestlers, and wrestlers treated at our emergency outpatient department were clinically evaluated. In addition, the relationships of head trauma with duration of the wrestling career of 1-16 years (mean 8 years) in the regular members, and less than 1 year in the five trainees, and body mass index (BMI) of 21.0-32.0 in the 16 subjects, excluding two trainees, was evaluated. Chronic symptoms were noted in four of the 18 wrestlers with long wrestling careers (16 years in 1, 13 years in 1, and 5 years in 2). Three wrestlers with symptoms immediately after head trauma showed recurrent retrograde amnesia and had low BMI (21.6, 21.6, and 23.1). Five wrestlers were treated at our emergency outpatient clinic, three required hospitalization and two showed intracranial traumatic changes on computed tomography (acute subdural hematoma in 1 and diffuse brain swelling in 1). Head trauma in female professional wrestlers is associated with longer wrestling career and low BMI. Periodic medical examinations are recommended to monitor for signs of head trauma.

Chronic trauma in sports as a cause of hypopituitarism

TBI is one of the most important public health problems in the world. Although the relationship between TBI and hypopituitarism has been known for a long time, neuroendocrine changes were investigated in detail recently. The prevalence of neuroendocrine abnormalities in patients with TBI is very high. Gonadotropin and GH deficiencies appear to be the most common defects. Although combative sports are very popular around the world, trauma due to sports is not generally considered as a cause of TBI in most of the epidemiological studies. All the studies regarding TBI in sports published so far in the literature based on neuropshycological or radiological assessment and no neuroendocrine changes were investigated. In a recent study, pituitary functions in amateur boxers have been investigated and it has been reported that boxing is a cause of TBI and isolated GH deficiency is very common among amateur boxers. It seems that acute or chronic head trauma in sports is a possible cause of hypopituitarism. In this review, current data regarding TBI in sports are discussed.