SC Golden Gloves
Boxing Safety Certification Course
Welcome to Session 2!
Session 2 Checklist
- Take the CTE Pretest (~10 minutes)
- Read the fact sheet (~5 minutes)
- Watch the videos (~30 minutes)
- Complete the reflection exercise (~5 minutes)
(Update 4/12/21: The CTE Posttest will be taken during Session 5)
What is CTE?
Written text: Chronic Traumatic Encephalopathy (CTE): A progressive neurodegenerative brain disease caused by repetitive head trauma.
Spoken by Dr. Ann McKee: Chronic traumatic encephalopathy is a progressive neurodegeneration. The most common neurodegeneration that we know about is Alzheimer’s disease, but CTE is similar. But, in this case, in the case of CTE, it’s triggered by repetitive head trauma. And we think that after sufficient amounts of head trauma, this disease starts to develop in your brain and then becomes a progressive, widespread brain disease as time goes on.
CTE is defined neuropathologically – you can’t even make the diagnosis without a neuropathological examination of the brain tissue. What we look for under the microscope is the deposition of an abnormal tau protein that clusters around blood vessels in the brain, and that’s a very distinct lesion – it’s a specific lesion for CTE. There’s no other disease that causes those changes in tau protein, and that’s how we make the distinctive diagnosis.
Written text: The symptoms of CTE can vary, but generally affect cognition, mood and/or behavior.
Spoken by Dr. Ann McKee: The symptoms of CTE can be variable, but, often time, if the personality shift, a behavioral change, maybe mood changes like depression, there are things like aggression and violent behaviors, impulsivity, a short fuse. Another common set of symptoms is memory loss, and difficulty planning and organizing, and difficulty with attention.
Written text: CTE is a progressive disease. Once triggered, it gets more severe with aging.
Spoken by Dr. Ann McKee: What we see are just isolated lesions, very tiny lesions, in the cortex of the brain or in the grey matter of the brain. They haven’t spread to the other parts of the brain. It’s just isolated focal lesions. That’s how it starts out. That’s the mildest form that we see in the youngest individuals we’ve looked at with CTE. When it gets more severe, and it gets more severe with aging, it tends to spread to other parts of the nervous system, and it spreads to other parts of the grey matter, it spreads to the deep nuclei of the brain, the brain stem, and it even can spread to the spinal cord. Eventually it becomes quite a devastating disorder with abundant tau protein in many, many regions of the brain.
Written text: Researchers believe the location of CTE lesions in the brain may determine what symptoms the patient experiences.
Spoken by Dr. Ann McKee: CTE in different individuals can manifest quite differently. Some people will be impulsive and violent, and other people will feel a mental fogginess, a lack of clarity, a feeling like they’ve lost control over their brain or their thinking. It varies from individual to individual. We’re not exactly sure why those differences occur, but we think it has to do with the location of the lesions, maybe one individual has it in the frontal cortex or frontal pole, another person may have it inferior temporally, and those different parts of the brain are very different in what they do. So the temporal lobes aggression and impulsivity, the frontal lobe sort of judgment, decision-making, and the combination of the pathology. Where it is in the brain determines what symptoms you might be suffering from.
Written text: Dr. McKee and the VA-BU-CLF Brain Bank researchers have diagnosed more cases of CTE than the rest of the world combined. Dr. McKee diagnosed the first CTE cases in ice hockey, soccer, college football, high school football, MMA, and baseball as well as the first case series of military veterans.
What are the Symptoms of CTE?
Written text: What are the symptoms of CTE?
Spoken by Dr. Robert Stern: As far we know, CTE has a variety of symptoms that include problems with memory and thinking, such as the inability to learn new information or remember what happened a day ago, problems with planning, organization, multitasking, and then there can be problems with mood and emotion. So things like depression or anxiety or agitation. There can also be problems with behavior. These are some of the more complex or difficult problems. Things like the inability to stop one’s impulses, to be out of control, or have a short fuse, or to even act aggressively or to have rage.
Written text: In later stages, memory and thinking problems can become severe enough to hurt someone’s ability to do routine daily tasks independently. This would be considered “dementia.”
Written text: Will everyone with CTE get the same symptoms?
Spoken by Dr. Robert Stern: I wish I could say that there’s a uniform way that CTE comes across in all people. We don’t know that yet — and I don’t think we ever will, because in most brain diseases or brain conditions it’s really variable from person to person or patient to patient. So with CTE, some people might have problems with mood and behavior earlier in life, some people might have problems with thinking and memory, but not until later in life. Some people may have some combination of all of that. And it varies from person to person. That’s what we’re trying to figure out. Why does it vary? Can we understand who might have what problems first or next or may never have them?
Study: Hits, Not Concussions, Cause CTE
Spoken by Dr. Lee Goldstein: CTE is the acronym we use for chronic traumatic encephalopathy. This is a neurodegenerative disease that involves the tau protein. It’s the same protein that builds up in Alzheimer’s disease, but this is not Alzheimer’s disease. This disease is associated with repetitive injuries to the brain that come from contact head injures in contact sports, as well as, as we’ve reported previously, military blast exposure. This is not the injury itself. This is the neurodegenerative disease that develops as a consequence.
What we have done in this paper is really three fundamental things. One, we’ve looked at the very earliest stages of this disease in teenagers with the earliest fingerprints of a neurodegenerative disease. It’s kind of staggering to even think about this – a teenager with a neurodegenerative disease. What we were able to do in this paper is to look at those very rare cases of post-mortem brains, brains received after death, from teenagers that had a relatively recent concussive or subconcussive head injury, and looked to see what their brains looked like when they died – days, weeks, and months afterwards, from another cause.
The important thing to know about the small number of cases is not that it is a small number of cases, but that we can learn from these even single cases, that will allow us to develop hypotheses we can test in the laboratory.
The first part is that we have a neurodegenerative disease in teenagers, and we can correlate this, A correlates with B. What we can’t determine from the human neuropathology is whether A causes B. That is, what is the relationship of the hit or the hits to the incipient disease. That’s what the second part of the paper is involved in focusing on. So, we want to know how these head injuries relate to brain damage and ultimately to CTE. And are those things connected? If so, how?
Blast exposure in experimental models that we did previously had to do with the blast wind, and what that led to was movement of the head. Knowing that it likely had something to do with the head motion, that was our hypothesis. We built the models to test that, to see if we can impart the head motion in a different way. In this case, with contact, to make the head move the same way. And we were able to do this with a large engineering team.
After even a few number of exposures, we could trigger not only the traumatic brain injury, which has been reported for many decades, but that we could actually trigger CTE pathology that was strikingly similar to what we see in people. So now that we have a model in which we can induce the disease, this allows us now to develop new ways of picking this up in really early stages of the disease process. What we did here was take advantage of an older technology called dynamic enhanced contrast MRI, which is a brain imaging technique, and we were able to pick up the type of damage that we saw in the brain, and now pick it up in the living animal. This is very helpful as we try to move this into the clinic to detect early fingerprints of the disease.
The main message of this work is concussion doesn’t cause the CTE, but, rather, the hit itself independent of concussion causes CTE.
Concussion Legacy Foundation. (2019, May 29). How diet, exercise, and socialization can help fight CTE [Video]. YouTube. https://www.youtube.com/watch?v=phvEwz_vaXg
How Diet, Exercise, and Socialization Can Help Fight CTE
Spoken by Dr. Robert Stern: There are a lot of things that people can do to keep their brain as healthy as possible. To hopefully slow down a disease if they have it. Or maybe even prevent it in the first place or slow it down early in life so they may not have any problems.
One, to have a diet that is going to fend off toxins and inflammation. And the best way to do that is what’s called the Mediterranean diet. And it’s a diet that has fruits and vegetables, nuts and legumes, like beans. Lots of olive oil and olives, and the good fish, the fish with those good fats in them like salmon, and very little red meat. And there’s been several studies that show that if you follow that kind of diet, this Mediterranean diet, it really seems to protect the brain from problems and maybe slows down a brain disease from getting worse.
One of the other key things to keep a brain healthy is exercise — continued aerobic exercise, not just pumping iron, and not flipping channels. But actual fast walking or running or going on a treadmill or swimming. Anything that will get that heart pumping. Not, you know, in a wild and crazy way, but just enough, 20-30 minutes, several times a week. Going for walks with the dog, but doing it in a way that gets that heart pumping. Something that keeps that heart going is going to be likely really helpful to protect that brain.
Then the next one has to do with social networks — staying engaged. Keeping some kind of connection with other people. Instead of just sitting home alone watching TV, calling someone on the phone, or going to some, you know, group of friends, or going to the senior center, or joining a book club, or going to the gym. Somehow keeping connections going seems to be really good at wiring the brain in a way that may help it from getting damaged further on.
But it’s really important to know that there are things that we all can do to keep our brains healthy. There are things that someone who may be afraid that they’re going to develop CTE can do. There may be people who think they already have it, and they want to be able to do something to keep their brains healthy. You know what? They’re all the same thing: (1) Good diet with those Mediterranean diet type of ingredients, (2) good exercise, and (3) keeping oneself socially engaged.
CTE: How Repeated Head Blows Affect the Brain
Written text: The science of CTE. What is CTE? Chronic traumatic encephalopathy
Spoken by Dr. Ann McKee: CTE has been associated with repetitive head impacts. That is, repetitive concussion and subconcussive injury in contact sport athletes, but also in military veterans.
Written text: Repeated head blows
Spoken by Dr. Ann McKee: With repeated impacts to the head, the brain inside the skull ricochets back and forth, it goes forward, it accelerates and decelerates, but it also goes rotationally. And that causes the brain inside the skull to actually elongate and stretch. And that stretching puts a lot of physical force on the individual nerve cells, especially the neurons and the axons, and that can lead to the buildup of tau.
Written text: What is tau?
Spoken by Dr. Ann McKee: Tau is a normal protein in the brain, and, normally, it is inside the nerve cell and it contributes to what we call the cytoskeleton or the skeleton of the cell. It helps hold up the cell’s shape. Under abnormal circumstances, like after trauma, when the nerve cells are damaged. The tau actually comes off the skeleton, it comes of the microtubules, and it starts clumping up, and, eventually, it will kill the cell if enough builds up over time.
Written text: Brain with CTE
Spoken by Dr. Ann McKee: An individual in his 40s. This is a former NFL player, a person of large stature. You can see that the ventricles, the areas of the brain that contain spinal fluid, they’re enlarged. This thinning … gets to be damaged more than the ventricle aspect, and that’s something that we’ve really only seen with CTE. We can see spaces near the hippocampus, which is part of the brain that’s important for learning and for memory. And we can see that there has been shrinkage there as well. To see this in such a young individual is quite startling.
Written text: CTE signs
Spoken by Dr. Ann McKee: We see a lot of CTE lesions on the top and the lateral sides of the frontal lobes, which is about 2/3 of the forward part of the brain. That’s what leads to the symptoms and signs of CTE. Loss of memory, some behavioral and personality change, and often mood changes like depression.
Written text: Prevention
Spoken by Dr. Ann McKee: The real key to preventing CTE is preventing exposure to head impacts. So anything an individual athlete can do to minimize the amount of head contacts, the number of falls, or blows.
Written text: What’s next?
Spoken by Dr. Ann McKee: If we can detect it in these young individuals, that will give us an idea about what triggers it. And then if we can detect it in those early stages, we have a really good path for treating it.
Fair but Firm Joe Cortez and Dr. Charles Bernick
Joe Cortez: Joe Cortez here with Fair but Firm, where tonight I have a special guest, Dr. Charles Bernick, the Associate Director of the Cleveland Clinic Lou Ruvo Center for Brain Health here in Las Vegas. Dr. Bernick, can you tell us a little bit about the studies that you’re doing already with fighters in reference to concussions. How can we better the sport, combat sports, and what studies have you found up-to-date?
Dr. Charles Bernick: Yes, so Joe, we’re really interested in the long-term effects of repetitive head impacts, and who better to study then, of course, combat sports and boxers. That’s where actually some of the information about chronic traumatic encephalopathy, which is
CTE, was described. So we have a study where we’re following 750 boxers and MMA fighters on a yearly basis, and we’re doing testing of their brains. We’re doing blood tests, genetics, we’re looking at their habits to try to understand who’s at risk of long-term consequences of head trauma, how we can recognize it early, and, of course, eventually, how do we intervene: Is it through changing policies in the sport? Training methods? Are there medications? All these things are questions that we really want to answer.
Joe Cortez: Now some of the fighters that you have, you have already like 750 combat sport individuals, how, the study that you’re doing with them, they’ve been going now for a number of years, how do you monitor the studies that you’re doing?
Dr. Charles Bernick: Yes, so each of the fighters comes in, they get an MRI scan of their brain. We get blood tests to look at markers of brain damage. We do tests of memory, reaction time. We take surveys of their mood and behavior. You get speech samples because slurred speech is such a common result of boxing. And by gathering all this information we’re really trying to understand how brain injury develops, and, of course, how do we detect it early because that could be the key.
Joe Cortez: One of the things that I’ve always said to trainers is that, while they’re having their training sessions, they have a tendency of having gym wars. They’re in the gym like they’re having a real fight, and sometimes it gets a little bit out of control, and these fighters are taking blows to the head, and they get knocked down, they get buzzed in ring and whatnot. I mean I see a bad thing happening in boxing. What have you seen from the study that you’ve been doing for fighters that come out from day one to where they are today, have you seen a drastic change in them, is it better, or what?
Dr. Charles Bernick: Well, one of the things we have discovered by using a blood test to measure some of the chemicals that are released by injured brain cells is that, yeah, the amount of sparring is associated with more damage. And probably a lot of the injuries that are occurring in boxing and other combat sports is during the sparring, it’s during the training. Actually when you talk to some more seasoned veterans, a lot of them spar less or they’re a little more careful because they understand that going into a fight with having a concussion or having some even sub-concussive blows puts you at a disadvantage.
Joe Cortez: Yeah, and one of the things that that I worried about when I was refereeing, I told the referees I’d rather see referee stop a punch too soon than a punch too late during that particular fight. But sometimes some of these fighters already come into the ring damaged goods, either from a foreign country they had received a knock out in the previous fight, or they might have just fought two weeks prior to coming to Las Vegas, and this is what scares us a little bit about having the information, a database. I’d like to see a universal database where everybody from every commission around the world, overnight, every commission around the world can get the results with these fighters. This way, everybody is up-to-date, and if we can save one life we’re ahead of the game. But we see a lot of these managers and trainers, they sneak in their fighters into a country or state, lying about the recent fights that they had, and we have no way to track them. I like to see a more of a database to help prevent that but a lot of these trainers come in bringing the fighters they know they got knocked out in training or they got buzzed really bad, they were supposed to report it, but they didn’t report it. And, now what happens is that they didn’t want to pull out of a fight because of big paycheck. It could be a couple of hundred thousand dollars or maybe a million dollar paycheck. And they don’t want to report it because they don’t want to lose that paycheck. So, you know, there could there be a suspension. Now you know in boxing that is an automatic suspension in the state of Nevada — either 120 days, could be 90 days, and sometimes 120 days, depending on the severity of the concussion that they’ve received, or the knock out, or whatever. And it’s mandatory that once they get knocked out in a fight or take heavy punishment, during the contest here in Las Vegas, it’s mandatory that they go right to the emergency room and get a CAT scan performed to see if there any damage there. What can you tell us a little bit about that?
Dr. Charles Bernick: Well I think your suggestion about having at least some database or repository that tracks a fighter over time, no matter where they are, would be huge. You know, I think this is why boxing has such a sketchy reputation, because, you know, it’s promoters or trainers that take advantage of their fighters. And so, if there was some way from a regulatory standpoint to control that, of course, again, you’d add another layer of safety into the sport. So certainly we don’t want fighters going and having had a recent concussion. We know that it’s easier for them to get knocked out. They can get more permanent damage. So, I think this is a big issue, and it becomes a regulatory issue, it becomes a legal issue.
Joe Cortez: Okay, now talking about legal, at UFC [transcription note: NFL] has had some issues most recently, because they had to pay out money to football players and ex-football players because the concussions they received from playing football. And there’s a lot of a lot of things going on with football and they’re saying, maybe banning football, there’s so much negative stuff going out there. I just read something about this fella Aaron Hernandez about that they did a study on his brain after he committed suicide while he was incarcerated, and now they did that, the family is suing the UFC [transcription note: NFL] because of that, the NFL, I’m sorry, and because of that, what can you tell me about that, football players?
Dr. Charles Bernick: Anybody who is involved in a sport where you can get repetitive head impacts, so whether it’s NFL, soccer, you’re a jockey, everybody, those are people are at risk of long-term head trauma. Now you have to have a lot of exposure: It’s not just playing high school football, for example, you have to have a lot of exposure. But they’re at risk. And, in the NFL’s case, there’s a obviously a big organization that has a lot of money that you can go after. Whether this is going to happen in other sports that’s to be seen, but I think from a societal standpoint, what we should be doing is trying to make these sports as safe as possible. There’s clearly good that you can get whether you’re playing football or, any of these, boxing or MMA — there’s a lot that you can get out of it that’s really positive. So we don’t want to take that away, but the real goal and the goal of our study, is how do we make these sports safer? How can we prevent long-term damage? And, that’s the goal.
Joe Cortez: Well you heard it here with Dr. Charles Bernick, Joe Cortez with Fair but Firm. See you next week
FightHype.com. (2019, July 20). Tim Bradley passionate plea after fighter rushed to hospital for surgery; implores “don’t take hits.” [Video]. YouTube. https://www.youtube.com/watch?v=lZzgZw0k4V4&feature=youtu.be
World Boxing Hall of Fame: Boxer Jerry Quarry. (2011, September 3). Anyone seriously considering boxing should see Jerry Quarry. [Video]. YouTube. https://www.youtube.com/watch?v=KVOoDdRTAAM
Many boxing programs are geared towards youth development, yet, recent research indicates there may be long term consequences for boxers who begin competing at a young age. CTE has been discovered in post-mortem brains of teenagers, which is evidence even young people can develop the neurodegenerative disease.
- Based on the research you have been presented with this session, what age do you think is appropriate to begin full contact boxing training and competition?
- How might you change your approach to coaching amateur boxers based on recent CTE research?
Abdolmohammadi, B., Dupre, A., Evers, L., & Mez, J. (2020). Genetics of chronic traumatic encephalopathy. Seminars in Neurology, 40(4), 420-429. https://doi.org/10.1055/s-0040-1713631
Bernick, C., Banks, S., Shin, W., Obuchowski, N., Butler, S., Noback, M., Phillips, M., Lowe, M., Jones, S., & Modic, M. (2015). Repeated head trauma is associated with smaller thalamic volumes and slower processing speed: The Professional Fighters’ Brain Health Study. British Journal of Sports Medicine, 49(15), 1007-1011. https://doi.org/10.1136/bjsports-2014-093877
Bernick, C., Banks, S., Phillips, M., Lowe, M., Shin, W., Obuchowski, N., Jones, S., & Modic, M. (2013). Professional Fighters Brain Health Study: Rationale and methods. American Journal of Epidemiology, 178(2), 280-286. https://doi.org/10.1093/aje/kws456
Bernick, C., Zetterberg, H., Shan, G., Banks, S., & Blennow, K. (2018). Longitudinal performance of plasma neurofilament light and tau in professional fighters: The professional fighters brain health study. Journal of Neurotrauma, 35(20), 2351-2356. https://doi.org/10.1089/neu.2017.5553
Bernick, C., Shan, G., Zetterberg, H., Banks, S., Mishra, V. R., Bekris, L., Leverenz, J. B., & Blennow, K. (2020). Longitudinal change in regional brain volumes with exposure to repetitive head impacts. Neurology, 94(3), e232-e240. https://doi.org/10.1212/wnl.0000000000008817
Bryant, B. R., Narapareddy, B. R., Bray, M., Richey, L., N., Krieg, A., Shan, G., Peters, M. E., & Bernick, C. (2020). The effect of age of first exposure to
competitive fighting on cognitive and other neuropsychiatric symptoms and brain
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Cantu, R. C., & Bernick, C. (2020). History of chronic traumatic encephalopathy. Seminars in Neurology, 40(4), 353-358. https://doi.org/10.1055/s-0040-1713622
Cherry, J. D., Babcock, K. J., & Goldstein, L. E. (2020). Repetitive head trauma induces chronic traumatic encephalopathy by multiple mechanisms. Seminars in Neurology, 40(4), 430-438. https://doi.org/10.1055/s-0040-1713620
Lee, B. G., Leavitt, M. J., Bernick, C. B., Leger, G. C., Rabinovici, G., & Banks, S. J. (2018). A systematic review of positron emission tomography of tau, amyloid beta, and neuroinflammation in chronic traumatic encephalopathy: The evidence to date. Journal of Neurotrauma, 35(17), 2015-2024. https://doi.org/10.1089/neu.2017.5558
Lee, B., Bennett, L. L., Bernick, C., Shan, G., & Banks, S. J. (2019). The relations among depression, cognition, and brain volume in professional boxers: A preliminary examination using brief clinical measures. Journal of Head Trauma Rehabilitation, 34(6), e29-e39. https://doi.org/10.1097/htr.0000000000000495
Lesman-Segev, O. H., Edwards, L., & Rabinovici, G. D. (2020). Chronic traumatic encephalopathy: A comparison with Alzheimer’s disease and frontotemporal dementia. Seminars in Neurology, 40(4), 394-410. https://doi.org/10.1055/s-0040-1715134
Mariani, M., Alosco, M. L., Mez, J., & Stern, R. A. (2020). Clinical presentation of chronic traumatic encephalopathy. Seminars in Neurology, 40(4), 370-383. https://doi.org/10.1055/s-0040-1713624
McKee, A. C. (2020). The neuropathology of chronic traumatic encephalopathy: The status of the literature. Seminars in Neurology, 40(4), 359-369. https://doi.org/10.1055/s-0040-1713632
Phelps, A., Mez, J., Stern, R. A., & Alosco, M. L. (2020). Risk factors for chronic traumatic encephalopathy: A proposed framework. Seminars in Neurology, 40(4), 439-449. https://doi.org/10.1055/s-0040-1713633
Shahim, P., Gill, J. M., Blennow, K., & Zetterberg, H. (2020). Fluid biomarkers for chronic traumatic encephalopathy. Seminars in Neurology, 40(4), 411-419. https://doi.org/10.1055/s-0040-1715095
Stein, T. D., & Crary, J. F. (2020). Chronic traumatic encephalopathy and neuropathological comorbidities. Seminars in Neurology, 40(4), 384-393. https://doi.org/10.1055/s-0040-1713628
Stephen, S., Shan, G., Banks, S. J., Bernick, C., & Bennett, L. L. (2020). The relationship between fighting style, cognition, and regional brain volume in professional combatants: A preliminary examination using brief neurocognitive measures. Journal of Head Trauma Rehabilitation, 35(3), e280-e287. https://doi.org/10.1097/htr.0000000000000540
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Session 2 Checklist:
- Did you take the CTE Pretest?
- Did you read the fact sheet?
- Did you watch the videos?
- Did you complete the reflection exercise?