Boxing has always been a controversial sport, mainly focused around blows to the head and the potential risk of acute brain injury and chronic traumatic encephalopathy. As a result of this controversy, the American Medical Association demanded that head guards be introduced into Olympic boxing at the 1984 Los Angeles games. There was no scientific basis for this nor were the head guards designed to reduce the risk of head injury. The head guards introduced were those used in sparring in the professional boxing gyms. These head guards were never designed to protect from head injury but were designed to reduce the incidence of cuts.
A study of rule changes in Olympic boxing over the last 59 years found that when head guards were introduced the number of stoppages due to blows to the head increased.1 In support of this finding, when the use of head guards has been studied in other sports, the evidence of reduction concussion is inconclusive.2,3
In 2010, a new form of boxing was introduced for AIBA boxers, World Series Boxing (WSB). The bouts are 5 rounds of 3 minutes each and are fought without vests or head guards using the same pool of boxers, referees, and judges as in other AIBA competitions.
We present here data from the first 3 years of WSB (no head guards) comparing the incidence of stoppages due to blows to the head with data from other AIBA bouts (head guards) over the same period. Furthermore, we present a case study from the 2009, 2011, and 2013 AIBA world championships where head guards were used for the 2009 and 2011 championships and were not used in 2013.
This is a cross-sectional observational study looking at major tournaments sanctioned by International Boxing Association (AIBA), the only international governing body of boxing recognized by the International Olympic Commitee, over the period 2009 to 2013. The information was recorded by ringside medical physicians who work in both AIBA competitions. The results were collated by the chief medical officer for AIBA (CB). Only stoppages due to blows to the head were included in this study. Stoppages due to all other reasons were excluded.
Referee stops contest due to head injury (RSCH) is a refereeing decision traditionally used by AIBA as a proxy for concussion. In 95% of the time, no loss of consciousness is involved but the appearance of the boxer at the instant of the blow or immediately after suggests a concussion may have occurred. Referees who are closest to the action are highly trained to recognize the signs and symptoms of concussion and often are the first to stop the bout indeed; Moriarity et al4 showed that only 1.7% of subsequently diagnosed concussions were not suspected by the referee. Every boxer stopped for head blows was examined by a physician, was restricted from boxing for a minimum of 30 days up to 1 year, and was treated for concussion. If there is any error in this proxy, it should equalize across both cohorts as the athletes, physicians, officials were from the same group.
95% CI of the risk ratio (RR) of the number of injuries between 2 groups was calculated by a simple Poisson model, assuming constant hazard per group. Two-tailed P values ≤0.05 were regarded as significant.
Table 1 shows that stoppages due to head blow have essentially been halved, whereas the incidence of cuts has increased considerably. The data indicate a 43% lower risk of stoppages (RR = 0.57) and 430% higher risk of cuts (RR = 5.30) when boxing without the head guard. Case study results from the last 3 senior men AIBA World Championships (Table 2) show that a decrease in stoppages and a considerable increase in cuts when the head guards were removed.
Since AIBA was founded in 1946, there have been no deaths in an AIBA sponsored tournament. This includes all boxers who boxed without head guards from 1946 to 1982 and all boxers with head guards from 1984 to 2015. Two intracranial bleeds have been diagnosed in AIBA competitions since 1946, in 2006 and in 2008. Both boxers were wearing head guards at the time of injury, both recovered with conservative treatment.
Controversy in boxing has centered on the perceived risk of head injury.5 The data presented here suggest that the addition of head protection in AIBA boxing may not protect against head injury. Studies have shown that the presence of the head guard reduces the force transmitted to the head.6 However, it is the rotational acceleration of the head that is believed to be the major factor in concussion or mild traumatic brain injury.7 Head guards provide padding over the forehead but only a thin strap under the chin although blows to the forehead are seldom the cause of a knock-out. Padding cannot be added under the chin as this impedes breathing as the boxer keeps the chin tucked. It is hypothesized that head guards, by increasing the diameter and surface area of the head, will lead to increased rotational force and subsequent stoppage. Furthermore, head guards are considered to increase the risk of blows to the head because the padding around the eyes limits the boxer's vision.
The most convincing hypothesis is that head guards give a false sense of safety and so boxers partake in more high-risk behaviors than they would have done were they not wearing a head guard.8 When a sport adopts head guards, technique often changes to use the head to gain advantage, as has been suggested to have occurred in American Football.9,10 In support of this hypothesis, the data presented here show approximately twice as many stoppages due to blows to the head when wearing a head guard.
This study shows an increase in the incidence of cuts after the removal of head guards. This increased incidence was greater than the decrease of cuts seen when head guards were made mandatory in 1984.1 The reduction of cuts when head guards were added can be approximated at 50%. The current increase in cut after removal of head guards may be accounted for by “weaponization” of the head caused by changes in boxing style that became advantageous with the addition of headgear. Since lacerations did not appear as frequently before head guards were mandatory, it is postulated that as boxers become more experienced and acclimated to boxing without head guards and coaches change their style to take account of the new rule, the rate of cuts will be reduced to previous historic levels. The mean average for 2015 (9 tournaments) was 11.4% (cuts/bout) or 5.7% (cuts/boxer/bout) (unpublished data).
Many different forms of head guards have been tried over the years as AIBA strived to find the most protective form of head guard. However, acceleration and deceleration forces that contribute to concussion will still remain irrespective of head guard design. In addition, emerging medical science indicates that subconcussion, cranial impacts which do not lead to recognized or diagnosed concussion, may be important in a cumulative way.11 To reduce the number of head impacts, surely the solution is to suppress or mitigate the number and strength of head contacts or head blows by changing boxing behavior through education and proper technique instruction—as is being attempted by AIBA HeadsUp program. Head guards could play a protective role in groups of boxers where concussions are extremely rare such as women boxers and young male boxers. However, there are no comparative studies in these populations. Similarly, gloves have evolved through the years. The older horse-hair “knock out” gloves have been replaced by gloves with more energy absorbing foams. Many cuts are still due to glove abnormalities such as roughness or stitching. It is hoped their continuing design improvements will prevent many cuts and attenuate blow strength.
Limitations of this study include the small sample size and the use of stoppages due to blows to the head as a surrogate for concussion.
This study shows that removing head guards from AIBA competition boxers seems to reduce the rate of stoppages due to blows to the head, a surrogate for cerebral concussion. In contrast, the incidence of facial cuts increases without head guards. Lacerations did not appear as frequently before head guards were mandatory. It is hypothesized that as boxers become more experienced without head guards and the educational heads up program comes into effect, then the rate of cuts will fall. Although counter intuitive, it would seem that removing head guards may reduce the already small risk of acute brain injury in AIBA competitions.
The authors thank the AIBA and the WSB Office for collating the WSB numbers from all the WSB ringside physicians.
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