The Sport Psychologist, 1990, 4, 55-62

Injuries in Boxing: Evaluations and Policy Decisions

Michael Maliszewski University of Chicago

Combat oriented sports and activities have come under increasing scrutiny by the media and professional groups. In particular, within the last 5 years boxing has been a primary topic of concern. A variety of medical groups- neurological, pediatric, and general practice-have conducted extensive sur- veys and provided position policy statements regarding dangers associated with involvement in such an activity. Although the American Psychological Association recently endorsed a position advocating close scrutiny and even- tual banning of amateur and professional boxing in 1987, surprisingly no serious review of the literature or empirical studies have been conducted with respect to a psychological evaluation of this sport. This article briefly reviews the evidence supporting the APA position on boxing.

The impact of injury sustained in boxing has been a central topic of discus- sion in the sports literature over the past 5 years. Several years ago psychologists in the United States added their input to this debate. On August 25, 1985, the American Psychological Association (APA) delivered a position statement call- ing for ringside evaluations of boxers during bouts and for other health measures in an attempt to curb injury to the brain and nervous system in boxing. APA's ultimate goal was to eliminate both amateur and professional boxing, which it characterized as a sport whose objective is to inflict injury. A press release issued at the time ("Psychologists Recommended," 1985) read as follows:

Be it resolved that the American Psychological Association: Encourage neuropsychological evaluations of boxers be given on a periodic

(one or two year) basis; Encourage ring-side evaluations during bouts to be done by individuals

who are trained to perform neurocognitive investigations of acute mental change;

Work to educate the American public, especially children and young adults, about the dangerous effects of boxing on the health of participants. The effects of boxing on the psychological and social enhancement of violence and aggres-

Michael Maliszewski is with the Department of Behavioral Medicine at Weiss Hos- pital (University of Chicago Hospitals), 4646 N. Marine Dr., Chicago, IL 60640.

sion should be brought before the public. Psychologists who give courses and who write textbooks that take up relations between behavior and the nervous system are asked to consider including material on boxing and brain damage i n their course and textbooks. . . .

(Work towards) the elimination of both amateur and professional boxing, a sport i n which the objective is to inflict injury;

Communicate its opposition to boxing to appropriate regulating bodies; Assist state psychological societies to work with their state legislatures

to enact laws to eliminate boxing i n their jurisdictions.

Despite legitimate and sincere concerns of the APA to delimit brain injury stem- ming from boxing, there has yet to be a review of the literature that explores the foundations upon which their proposal rests.

The focus of this article will be to review the evidence available to date on this subject. To this end, a survey and evaluation of empirical studies and clinical observations will be briefly outlined in several areas: medical findings, neuropsychological assessments, and psychological studies.

Medical Findings Concerns about the effects of boxing had been highly publicized in various medi- cal journals, particularly during 1983 and 1984, with physicians addressing the medical complications that arose from participation in this sport. To this end professional boxing had already been banned in such countries as Sweden, Norway, Poland, and Czechoslovakia. Based upon various research investiga- tions, case reports, and clinical observations, a number of medical organizations had presented position statements with respect to boxing. These findings appear in Table 1.

Table 1

Organizational Positions on Boxing

Organization Year Resolutionlposition statement

American American

Academy of Neurology Academy of Pediatrics

American Alliance for Health, Physical Education, Recreation and Dance

American Medical Association American Osteopathic Association

Australian Medical Association British Medical Association Canadian Medical Association World Medical Association

Ban boxing Opposed to boxing for child or

young adult Encourages elimination of boxing

Ban boxing Commends actions of USA

Amateur Boxing Federation to make boxing safer

Opposed to boxing Abolish boxing Ban boxing Ban boxing

Injuries in Boxing 57

It can be seen that with the exception of the American Osteopathic Asso- ciation, which took a less forceful stance, all of the organizations delivering a position statement expressed general opposition to the sport or called for its elirni- nation altogether. The American Neurological Association supported the posi- tion taken by the American Academy of Neurology, and the Canadian Psychiatric Association deferred its position to the decision made by the larger Canadian Medi- cal Association. The strong stance taken by these organizations stemmed largely from many empirical or clinical studies published over a number of years reveal- ing a wide array of injuries sustained through boxing. A general range of these studies and injuries reported appears in Table 2.

It was quite clear that over the previous 30 years much evidence had been accumulated from different areas suggesting that serious damage could result from this sport. Nonetheless, not all physicians supported the banning of boxing even

Table 2

Medical Injuries in Boxing -

Studylreview Injury reported

Amelar & Solomon (1954) Bellham & Adler (1985) Bogicevic, Jokanovic, & Micic (1966) Borgogna, Re, Re, Viterbo, & Torreri

(1 984) Casson, Sham, Campbell, Tarlau, &

DiDomenico (1 982) Doggart (1 955)

Dombrovskii (1 974) Geller (1953) Karpov (1 985) Kvist & Kvist (1 983) Paulsen & Hundhausen (1971) Picchio, Zini, & Sorbini (1985) Ross, Cole, Thompson, & Kim (1983)

Schmid (1970) Simonsen (1 980) Stiller & Weinberger (1985)

Acute renal trauma Pneumothorax Nasal bones Maxiofacial injuries: trauma to the tongue,

lips, teeth, TMJ; bone fracture Cerebral atrophy in 5 of 10 boxers

(those with most bouts) Lesions of outer and inner eye and visual

pathway Dentallmaxillary injuries Paranoid psychosis Damage to metacarpal bones Knuckle injuries Hearing damage Shoulder and elbow injuries Cerebral atrophy correlating with number

of boxing bouts Kidney lesions Fatality Post-mortem neuropathologic studies: Abnormalities of septum pellucidurn Cerebellar abnormalities Cerebellar scarring and atrophy Degeneration of specific nuclear groups

(substania nigra, locus ceruleus, and nucleus basalis of Meynert)

Regional occurrence of neurofibrillary tangles

prior to the appearance of formal position statements in 1983 and 1984. A common argument made in support of boxing was that, using data derived from mortality rates, boxing was safer than other sports. For example, Moore (1980) analyzed fatalities per 1,000 participants in various sports between 1945 and 1979 and ob- served the following rates: college football, .03; motorcycle racing, .07; scuba diving, 1.1; mountaineering, 5.1 ; hang gliding, 5.6; skydiving, 12.3; and horse- racing, 12.8. Boxing fatalities were third in least frequency: .13. A total of 335 deaths on both amateur and professional levels was observed in this 35-year survey. While much of the literature continues to argue against boxing, the de- bate still rages in most medical journals and the issue is far from resolved. Thus psychological and neuropsychological studies would be most useful in providing additional findings and assessments to further clarify this matter, given the initial impetus provided by medical and clinical research.

Neuropsychological Assessment Wile data have slowly accrued from many medical studies, few studies have included some type of neuropsychological evaluation of boxers. To date, only six studies have appeared in the literature. A review of their findings appears in Table 3. Regrettably, overall results are inconsistent. Even with the four studies reporting positive findings (i.e., impairment), close comparison of results reveals inconsistencies (e.g., different areas of impairment are discerned through use of the same or different test instruments). Further, most of these studies had a num- ber of methodological weaknesses. Roberts' (1969) investigation was the only study in which subjects were randomly selected. The study of Kaste et al. (1982) did not provide any test scores, statistical analyses, or criteria of normality. It also shared with other studies (Casson et al., 1984; Johnson, 1969) the lack of a control group for comparison. The two studies using controls (Drew, Templer, Schuyler, Newell, & Cannon, 1986; Thomassen, Juul-Jensen, DeFine Olivarius, Braemer, & Christensen, 1979) had different results. Interestingly, with the excep- tion of the study conducted by Drew et al. (1986), all of the neuropsychological evaluations were a component of broader medical studies exploring the issue of medical injury. Generally speaking, overall findings of these studies have done little to resolve the medical or health related concerns addressed in the previous section or noted within the APA position statement itself.

Psychological Studies Investigations in this area are amazingly few in number. A review of the litera- ture dealing strictly with the psychological aspects of boxing revealed only three studies that used psychological tests to assess outcome of participation in this activity. Findings of these studies were either mixed or actually had a favorable outcome. In a study of some 300 cadets, Anderson (1979) compared the degree of change in self-concept among individuals who participated in amateur boxing or gymnastic training. Based upon evaluative criteria used in the Tennessee Self- Concept Scale, significant changes were observed among individuals participat- ing in each of these sports. For those receiving high grades on the basis of their performance, greater positive changes in self-concept were observed with the boxers as opposed to gymnasts.

Table 3

Neuropsychological Evaluations of Boxers

Exam Study findings Tests administered Deficits

Casson et al. Positive Trail making test (Reitan) (1 984)

Drew et al. (1 986)

Johnson (1969)

Kaste et al. (1 982)

Roberts (1969)

Thomassen et al. (1 979)

Positive Quick neurological screening test, Randt memory test, Halsted-Reitan neuropsychological test battery (aphasia screening, trails, fingertip number writing, Seashore rhythm, tactile performance, finger tapping, and category tests).

Positive WAlS Benton visual retention test, Auditory word learning test.

Positive WAlS (information, similarities digit span, block design, object assembly subtests); Wechsler memory scale, Benton visual retention test, Purdue pegboard, trail making test (Reitan), Wisconsin card sorting test.

Negative Ravens progressive matrices (nonverbal intelligence), Mill Hill vocabulary test.

Negative WAlS Luria

Every boxer (N = 18) had at least one abnormal score when compared with established norms. General im- pairment index (% of abnormal neuropsychological test scores) correlated significantly with number of professional flights. 14 abnormal scores on 5-sec recall Bender. 13 abnormal scores on verbal Wechsler memory test. 11 abnormal scores on visual Wechsler memory test. 15 of 19 boxers scored in impaired range of Reitan impaired index. (Only comparable to controls overall in Seashore rhythm, finger tapping, and category tests). Supports "punch-drunk" syndrome observations. 17 ex-boxers; 11 of 15 cases presented with ab- normal findings (3 abnormal on all 3 tests, 5 ab- normal on 2 tests, 3 abnormal on 1 test). 12 of 14 boxers took more time to complete trail- CI

2. making test than normal; other test scores no differ- 3. ent from normal. 2

5' Vocabulary (due to education level). g Motor dysiunction of the left hand (after correction 09

for diffelences in education, age, and vocabulary). 3

60 Maliszewski

An Italian study of amateur/novice ranked boxers by Grandonico, Francone, and Calderaro (1982) involved submitting a general questionnaire to some 85 boxers. Findings from this self-report inventory revealed boxing to be useful in terms of the psychological development of its practitioners and also helpful in developing "creative aggression," which is channeled by the rules of the sport and obliges the boxers to behave in a controlled, purposeful, and socially accept- able manner. Finally, a Swiss study conducted by Rauchfleisch and Radu (1983) involved administering a battery of psychological tests (Rosenzweig Picture Frus- tration Test, Freiburger Personality Test, Color Pyramid Test, Benton Test, and an attention span test) to 125 amateur boxers. Test results revealed that boxers had personalities characterized by depressive problems and repressive inhibition which were not perceived by the boxers themselves. Although boxers exhibited few neurotic symptoms, boxing served to master latent conflicts that were dynamic and aggressive in nature. Overall, despite the more favorable findings here, all of these studies were limited by a lack of controls, randomization, and cross- sectional study design.

Conclusions

A review of the literature reveals that both neuropsychological evaluations and psychological assessments of participation in boxing are as yet inconclusive. It would initially appear that a stronger case against boxing is derived from the medi- cal literature. But even here the case is not closed. Addressing the medical and neuropsychological findings to date, Stiller and Weinberger (1985) conclude an excellent review article as follows:

Recent studies provide evidence that brain damage does exist in modem boxers and suggest that subclinical brain damage is likely to be more prevalent than obvious clinical dysfunction. There is clearly a discrepancy between subclinical evidence of neurological involvement (for example, clinical exam and neuro- logical testing). The latter tend to show less frequent and consistent evidence of brain damage in boxers than does the CT scan. Although it is tempting to assume that an abnormal CT scan presages the development of neurologic dysfunction, it is not clear that this is the case. The prevalence of the syn- drome, risk for progression to functional deficit, warning signs, and the natural history cannot be defined at this time. The only way to better define these parameters would be a controlled prospective study, which has yet to be under- taken. (p. 355)

It appears that this suggestion is being taken seriously by the medical and sports establishments. In 1986 the USA Amateur Boxing Federation announced plans to conduct an epidemiological study of 220 amateur boxers to determine if central nervous system damage will occur even with protective headgear (Gunby, 1986). Testing will include computer analyzed EEG, limb tremor observations, auditory-evoked response studies of the brainstem, and a battery of neuro- psychological tests. This study is expected to take place over a 4-year period. As to the current American Psychological Association position on boxing, the present stance appears somewhat premature and should be reconsidered with close attention to currently available data (albeit limited and inconclusive) upon which

Injuries in Boxing 61

we may propose a strong, logically developed premise concerning the psycho- logical strengths and limitations of boxing, amateur and professional alike. Follow- ing a directive initiated by medical organizations, it is argued here that a task force be established to investigate the psychological and neuropsychological aspects of this subject from an unbiased, empirically and clinically sound foundation. Consideration should be given to differentiating amateur from professional box- ing in such proposed studies. To this end, the newly established Division 47 of APA (Exercise and Sport Psychology) might be an appropriate starting point for initiating such a forum.

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Manuscript submitted: January 1 1, 1989 Revision recp3~ed: April 3, 1989