Blow by blow

Some serious brainpower has been directed at the dangers of being struck in the head, writes Shane Gilchrist.

It’s almost noon on a Friday at an inner-city Dunedin gym. Far from the hubbub of the build-up to Joseph Parker’s WBO world heavyweight title fight in Auckland today, a couple of teenage boxers are sparring, a quiet yet focused scene casually witnessed by fewer than half a dozen souls, whose ranks include an IT student, a businessman and a schoolteacher.

Slap, thwack, slap ... gloves meet gloves and, occasionally, flesh. Which is, after all, the point of the sport: generated by muscle, augmented by a turn of the hip and shoulder, a change of weight, kinetic energy is transferred to another human frame.

According to the International Boxing Association, a scoring blow is one, "which, without being blocked or guarded, lands with the knuckle part of the closed glove of either hand with the weight of the body on any part of the front or sides of the head or body above the belt, without infringing the rules".

Physiology has its rules, too. And when it comes to our grey matter, it’s black and white: the brain isn’t designed to withstand too hard a blow.

Monty Betham, the former Warriors and Kiwis rugby league player who turned to professional boxing recently, is only too aware of this: six weeks ago, he made the decision to retire after he was diagnosed with a brain bleed earlier in the year.

Contacted this week, Betham declined to speak to the Otago Daily Times, apart from commenting that he was "done talking about my career and the decision to end it".

The 38-year-old father of two was preparing for the defence of his New Zealand cruiserweight crown against James Langton when, following an eight-round sparring session in June, he felt pain at the back of his head, despite not feeling stunned by any of the punches.

Betham was advised to undergo a concussion test. He passed, but his symptoms got worse.

"Progressively, my body started stiffening up ... to the point where I couldn’t even get out of bed. Even turning over in bed was extremely painful," he told the New Zealand Herald following his retirement announcement in late October.

"I had a brain bleed or head bleed, and the fluid leaked down the spine into the lumbar area, which just crippled me. The scary thing is if that hadn’t happened, I would have fought because I had passed the concussion test. I would have fought a 10-round fight with a brain bleed. I could have been history."

Betham’s decision follows a string of boxing-related headlines: in September, Neville Knight (49) collapsed and died during a fundraising bout in Hamilton (although he did not die directly from a hit, instead collapsing in what his trainer, Dion McNabney, described as a "freak medical event"); later that month, 25-year-old Scottish boxer Mike Towell died a few days after suffering bleeding and swelling to his brain when he was knocked out during an elimination bout for the British welterweight title.

Described by Dunedin surgeon and researcher Prof Darryl Tong as "basically jelly inside a bowl of fluid that sits on a stalk", the brain suffers concussion when exposed to a front-on impact greater than 96.1g (g = acceleration of gravity or 980.665cm/sec2). However, the impact can be magnified depending on the angle, or rotational force, of the blow.

"The link between concussion and contact sports such as boxing is well known," Prof Tong says, referring to various studies.

These include one published in the British Medical Journal in 2015 that found repeated head blows sustained by fighters could lead to slower cognitive processing speeds as well as shrinking certain areas of the brain.

"Repetitive head trauma may be a risk factor for Alzheimer’s disease and is considered the primary cause of chronic traumatic encephalopathy (CTE)," the authors of the study wrote.

Alzheimer’s is a well-known form of dementia, while CTE is a progressive degenerative disease of the brain linked to memory loss, confusion, impaired judgement, impulse control problems, aggression, depression, and progressive dementia.

Jane Millichamp, a professional practice fellow and registered psychologist within the dean’s department of the Dunedin School of Medicine, says CTE is associated with repeated injuries to the brain, and is especially prevalent in sports such as boxing, rugby and wrestling.

"Boxing is the sport that appears to have the highest rate of CTE. This may be due to the fact that boxing involves a deadly combination of repeated blows and the application of extreme rotational forces to the brain.

"While research on CTE is in its infancy at present, there are some generally observed symptoms, involving: cognitive malfunctioning (problems with attention, concentration and memory, disorientation, confusion, etc); emotional and behavioural problems (irritability, apathy/lack of motivation, anger, suicidality); movement and motor disorders (slurred speech, poor gait)."

The symptoms appear gradually and progress over time, Dr Millichamp explains. The onset of CTE is usually in mid-life, sometimes many years after the initial trauma has occurred.

"One of the most worrying aspects of this disorder is its delayed onset and the fact that it is often difficult to detect or diagnose at the time when the damage is being done.  The most conclusive evidence of CTE is only available after the individual has died and pathological analysis is possible."

A person who has been concussed can suffer from problems with balance, vision, fatigue and cognition, all of which increases the likelihood of a subsequent accident or misjudgment. Additionally, a concussed brain is more susceptible to being damaged again. Hence the related problem of "second-impact syndrome", when a person suffers a further concussion before the initial one has healed.

A 2005 US study looked at the specific biomechanics involved in boxers’ punches, comparing them with  laboratory-reconstructed American Football concussions (also a subject of continuing research).

Eleven Olympic boxers, weighing between 51kg and 130kg, delivered a range of blows to the head of a dummy: the shots included hooks, uppercuts and straight punches to the forehead and jaw. The results showed a hook produced the greatest punch force, causing head "translational and rotational accelerations" consistent with NFL concussion impacts. Yet Prof Tong is attempting to shed more light on lower-level — but nonetheless significant — head knocks.

"Anything over 96.1g-forces means concussion and is very well-supported in the scientific literature. However, what we don’t know is what happens at a level below that, these smaller repeated knocks. No-one has established those thresholds yet and that is why we are researching this area."

A maxillofacial (face and jaw) trauma surgeon at Dunedin Hospital who works regularly in conjunction with neurosurgeon colleagues on patients with both head injuries and facial injuries, Prof Tong has helped develop a "skin-skull-brain" model to better measure impact forces.

He is working with a group of researchers at the University of Otago and helped establish the South Island Interdisciplinary Brain Injury Research Group , which combines expertise in biomaterial sciences, sports medicine, physiotherapy, neurosciences, bioethics and psychology.

The University of Otago is currently heavily involved with sports-related concussion and innovative research using sensors worn by the Otago rugby team has received  some attention.

When the human head is subjected to impact, kinetic energy is transmitted to the brain. The literature describing various simulant head models cannot be realistically compared to the human head, yet obtaining in vivo data from cranial impact in humans is ethically unobtainable.

Instead, Prof Tong and others, including biomaterials expert Associate Professor Neil Waddell, have developed an anatomical forensic head model (complete with brain fluid), which they strike with a bamboo sword (as per the martial art of kendo).

Why a sword instead of, say, a boxing glove?

Prof Tong says it’s easier to measure the effects of its force.

"There is too much variance in the action of punching. There’s no standardisation. The transfer of kinetic energy through facial bones and musculature to the brain varies depending on angle of strike, the strength of the person striking etc.

"However, by using kendo, there are specific strike zones, a certain area of the head that is reliably hit while a person is wearing protective headgear. Anecdotally, people have talked about seeing stars or ringing in the ears when they are hit hard in kendo."

It is hoped whacking Prof Tong’s head model with a stick  will provide answers to several burning questions: What’s the amount of force involved with subconcussive head injury? Can it be quantified? Can a threshold (or range of force) be developed to help predict subconcussion? Given repetitive injury over time is a key factor in the development of CTE and post-concussive syndromes, the importance of identifying such thresholds is obvious.

"We don’t know what those thresholds are yet. It’s a work in progress," Prof Tong says.

As the weight of evidence about the dangers of being hit in the head continue to mount, it begs the question: why do people still choose to box?

Ryan Henry, a New Zealand boxing selector, member of the South Island high-performance development panel and an executive member of the New Zealand Boxing Coaches’ Association, points to the notion of free will.

"People have a choice to box, just like people have a choice to do base jumping.

"I don’t think any sport can be safe. Look at horse-riding; it’s one of the most dangerous sports there is. What about motorsport?"

Director of the New Zealand Fight and Fitness Academy in Dunedin, Henry has been involved in boxing most of his life, "but solidly for the past 20 years, including about 15 years of coaching".

He also holds a black belt in jiu-jitsu.

"I have seen knock-outs but they are few and far between, especially in amateur boxing, where you only have three rounds. There is a referee who will normally put a count on if he sees a shot connect, even if a person doesn’t seem dazed. The corner can also throw in the towel."

Still, Henry says he does know of a few people who have been in the sport "too long".

"A few older coaches that I used to know years ago have probably suffered a little bit. Looking at them in their 70s and 80s, there was a bit of an effect, I’d say."

He says he does his utmost to reduce the risks.

"For starters, I teach people how to block properly, where to place their chin, how to keep their head moving. There is a sense of responsibility. I’m a member of the New Zealand Coaches’ Association, which disciplines coaches, including stripping them of their boxing licence, if they don’t abide by the rules.

"I’d never put mismatched fighters in the ring, nor would I put in a boxer who was experienced but hadn’t kept his or her fitness or skill level up to par."

Henry accepts there are dangers, but believes the benefits of the sport outweigh the risks.

"For instance, how many youths are kept off the streets because of gyms like this? Kids come in and get fitter, stronger, learn respect. Many people, all around the world, are bettering their lives because of boxing."