Fighting the ravages of head trauma

Yes, boxing is a sport. Yes, there is theoretically as much emphasis on not being hit as on hitting one's opponent. Yes, there are plenty of purists who enjoy the defensive wizardry of a Pernell Whitaker or Floyd Mayweather Jr.

But there is also no question that what attracts most casual fans to boxing -- and what excites its hard-core supporters as well -- is a knock-down, drag-out fight, a give-and-take battle in which punches are swapped with abandon. And if that fight ends with a stoppage, with one man knocked out or no longer able to defend himself, then so much the better.

Enthralling as such a finish may be, it's also the most dramatic illustration of the fundamental reality of boxing: Each direct hit to the head jars the brain, and punches delivered in enough numbers or with enough force injure the brain sufficiently to bring about temporary defenselessness or even unconsciousness.

That damage, however, is largely short-term. What about the long-term, the consequences of taking punches not just during one fight, but during a lifetime of fights from a career's dawn to its sunset, not just knockout blows but thudding jabs, not just on the main stage but also out of public sight, in gyms and camps?

Anyone who has spent much time in the orbit of boxing or around boxers has come across at least one fighter who shows the signs -- most conspicuously, slurred speech or uncertain movement -- of having been punched in the head more often than a human being should be. Alas, despite the symptoms, there's also the chance that fighter is still plying his trade, is still permitted to throw -- and more troublingly, receive -- punches for money.

There are many reasons why this may be so: the fact that the fighter wants to, the fact that nobody cares enough to stop him, the fact that the state or states in which he is licensed have insufficient or virtually non-existent testing standards. But even in those jurisdictions where boxers have to make some effort to prove they are fit to fight, chances are that even a pugilist who to most people's ears and eyes ought to be protected from himself is able to clear the requisite hurdles.

"What's so hard in boxing is that a person watching at home can say, 'This guy's been in the ring too long,' and yet medical personnel seem to be the last to know before they put a stop to a fighter's career," said Margaret Goodman, former chair of the Nevada State Athletic Commission's medical advisory board and now president of the Voluntary Anti-Doping Association.

He passed the tests is the fallback position adopted by innumerable promoters, managers and administrators to justify the continued career of boxers who are clearly diminished. To a large extent, that's understandable. The problem, Goodman points out, is that despite continuing medical advances, "by the time tests are abnormal, the fighter is generally already physically pretty far gone."

It is a problem that Dr. Charles Bernick is aiming to solve.

Bernick is the principal investigator for the Professional Fighters Brain Health Study, a multiyear effort being conducted out of the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas. The aim of the study, explains Bernick, essentially can be distilled into three categories.

"One is to see if we can detect the earliest changes of damage," he said. "How early can we detect damage? Second, to see if any of these changes are predictive. Do they indicate that somebody is on the way down? And the third is to better understand why some individuals are more susceptible than others. Is it that they don't really have the same exposure, or are there other factors?"

Key to being able to make those determinations is to study fighters -- boxers and mixed martial artists -- at multiple career stages: those who are just starting out, those in their primes, those at the end of their careers, and those who have retired. And as a control group, the study is also incorporating people who match the age and education of the boxers in the study, but who have never been involved in combat sports. The study involves annual MRIs of participants' brains, a series of cognitive tests, and voice analyses.

"We're realists," Bernick said. "We know most young athletes would not participate in this just to participate in a study -- although some do."

So Bernick and his team take advantage of the fact Nevada requires every fighter to have at least one MRI of his or her brain prior to licensing by offering a free MRI annually.

"That can save [a fighter] a thousand bucks," Bernick said. "Plus we're also offering now, in the second year, the blood test they need for licensure. They need their blood drawn to test for hepatitis and HIV and that kind of stuff, and we draw blood tests looking for their genetics and other markers that may be in the blood."

The center's Las Vegas location helps in that, not only does Sin City host an abundance of fighters appearing on cards both large and small, it's also home to UFC and Top Rank, both of which have bought fully into the project (as have Golden Boy Promotions and others).

"We encourage all our fighters to take part," Top Rank public relations director Lee Samuels said.

Among them is undefeated Las Vegas junior featherweight Jesse Magdaleno, 20, who has been participating in the study since its inception early in 2011.

"At first I was a little scared," Magdaleno said, an acknowledgment that if some fighters are reluctant to join the project, it's because of fear of what they might discover. "Every time you go back, you always have that second-guessing in the back of your head, like, 'Boy, I hope I don't mess up this time,' or 'I hope I do better this time than I did last time.' "

Participating in the study is not an especially onerous or time-consuming commitment: one visit, lasting a total of 2½ hours, each year -- although Magdaleno concedes that some of the required tasks, while simple in concept, demand some concentration.

"They have me doing the MRI, they have me do these things like read a little story, and they have me do things like connect the dots and numbers and alphabets," he said. "It's a lot of tricky stuff like hand-eye coordination."

Despite his youth and a professional career that to this point comprises only 11 fights, Magdaleno reveals a worldly wisdom of the merits of the Ruvo Center study and the need for understanding what happens inside a boxer's skull.

"My health comes first," he said. "I love boxing from the bottom of my heart. But at the end of the day, it's me who's in the ring, not the fans or any other fighter. It's me. So I've got to be sure that I'm making the right choice, because at the end of the day it's my health."

Largely spurred on by tragedy, other sports -- notably football -- also have begun to pay greater attention to chronic brain injuries. But the Ruvo Center study is unique in that it aims to build a comprehensive database of information, not just of athletes who already have suffered damage, but also of those who as yet have not, to try to understand at what point and under what circumstances that damage may take place.

"In some sense, not to brag, but we're leading the field," Bernick said. "Even with NFL players, there hasn't been, that I'm aware of, any sustained study of players at the time that they're getting their exposure. The action is happening when these guys are starting to get their exposure. And there is nothing in hockey, in NFL, in rodeo, all those sports in which you might think people are most at risk from head trauma, that looks at impacts on active athletes."

Already, Bernick and colleagues have announced some preliminary findings. There appears to be a threshold at which repetitive blows to the head begin to produce measurable changes such as memory loss and cognitive abilities. Not surprisingly, the biggest indicator of such changes is the length of a fighter's career and the number of bouts in which he or she has engaged.

Breaking up participating fighters into three groups -- those who have boxed less than six years, those who have competed between six and 12 years, and those whose careers exceeded 12 years -- the team found that brain volume actually began decreasing among members of the second group. Obvious symptoms, however, such as declines in memory and mental processing, tended to show up only in those who had been fighting for 12 years or more.

In other words, the time for a fighter to quit isn't when he has trouble remembering things or starts slurring his speech; by then, it's too late and the damage is done.

But many questions remain, questions that Bernick and colleagues hope to answer. Before major damage occurs, are there tell-tale signs that deterioration is underway? If so, what are they? Once such changes have been noticed, can they be halted, or is progression inevitable? At what point should a fighter stop, or at least fight less?

There are, of course, multiple factors involved in fighter safety beyond the purely scientific, not least being the desire to ensure that safety and the willingness to tell a boxer that enough is enough.

"A license to fight should always be considered a privilege, and not a right," Goodman said. "But it takes a lot of fortitude on the part of a commission to deny a fighter that license."

But if the study progresses as hoped, Bernick hopes it at least will be able to provide the information on which those kinds of crucial decisions can be based.

"At this point, to be honest with you, I don't think we can say much of anything, because we don't know," Bernick said. "To just say arbitrarily, 'Well, you should have an MRI scan every year' -- well, that might be the case, but what are you looking for? What kind of changes? I hope that from our study will come specific recommendations that you can provide to an athletic commission and the fighters themselves and say, 'Look, if you've fought a certain amount, then you need closer scrutiny, and if certain things start evolving on your test, that's when we decide you either need to stop or fight less frequently, or start some treatment.'

"Those are the kind of conclusions we want to come out of this with, to be able to give people direction based on scientific recommendation."