MEDICAL AND SAFETY REFORMS

IN BOXING
Barry D. Jordan, MD
New York, New York

The continued existence of boxing as an ac- reforms implemented by the proponents of box-
cepted sport in civilized society has been long ing are discussed.
debated. The position of the American Medical
Association (AMA) has evolved from promoting
increased safety and medical reform to recom-
mending total abolition of both amateur and For decades there have been heated outcries for the
professional boxing. In response to the AMA op- abolition of boxing for medical and moral reasons.
position to boxing, the boxing community has at- Short of its abolition, others have called for health
tempted to increase the safeguards in amateur and safety reforms. Critics of boxing state that self-
and professional boxing. regulation of the sport by its participants and sup-
The United States of America Amateur Boxing porters has been insufficient. In response to the grow-
Federation, which is the national regulatory ing public debate and mounting criticism concerning
agency for all amateur boxing in the United the safety standards of boxing, the boxing community
States, has taken several actions to prevent the has introduced several medical safeguards. The
occurrence of acute brain injury and is currently United States ofAmerica Amateur Boxing Federation
conducting epidemiologic studies to assess the (USAABF), the New York State Athletic Commission
long-term neuropsychologic consequences of (NYSAC), the Association of Boxing Commissions
amateur boxing. In professional boxing, state (ABC), and the federal legislation for the formation
regulatory agencies such as the New York State of the United States Boxing Commission (USBC)
Athletic Commission have introduced several have all been instrumental in addressing the medical
medical interventions to prevent and reduce issues that plague amateur and professional boxing
neurologic injury. The lack of a national regula- alike. Critics of boxing are extremely familiar with its
tory agency to govern professional boxing has shortcomings, but are uninformed about the health
stimulated the formation of the Association of and safety reforms that have been introduced. The
Boxing Commissions and potential legislation for following review was conducted to summarize the
the federal regulation of professional boxing by most recent health and safety interventions.
a federally chartered organization called the An adequate understanding of the medical oppo-
United States Boxing Commission. The AMA's sition and intervention concerning boxing requires
opposition to boxing and the medical and safety knowledge of the medical hazards involved. Because
the utmost medical concern in boxing is potential
From the Sports Neurology Program, Department of Neurology, brain damage, the epidemiology and pathophysiology
The New York Hospital-Cornell Medical Center, New York, New of acute and chronic brain injury need to be consid-
York. Requests for reprints should be addressed to Dr. Barry ered. Although a complete discussion of the neuro-
Jordan, Sports Neurology Program, Department of Neurology,
The New York Hospital-Cornell Medical Center, 525 E. 70th logic aspects of boxing is beyond the scope of this
Street, New York, NY 10021. paper, the review by Jordan' is quite comprehensive.

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REFORM IN BOXING

TABLE 1. RECOMMENDATIONS OF THE AMERICAN TABLE 2. RECOMMENDATIONS OF THE AMERICAN

MEDICAL ASSOCIATION COMMITTEE ON MEDICAL ASSOCIATION COUNCIL ON
MEDICAL ASPECTS OF SPORTS, 1962 SCIENTIFIC AFFAIRS, 19833
1. A thorough medical examination of each contestant 1. Encourage the establishment of a National Registry
prior to bouts by a physician responsible for of Boxers for all amateur and professional boxers,
determination of the boxer's fitness to participate including sparring-mates, in the country
2. At least. one physician present at all bouts with 2. Plan and conduct a conference with the appropriate
absolute authority to terminate the contest for representatives to review criteria for the physical
medical reasons examination of boxers, to determine other
3. Interruption by the referee or physician of any bout comprehensive medical measures necessary for the
with the opponent declared winner when a
prevention of brain injury, and to develop specific
contestant sustains more than one knockdown in
criteria for the discontinuance of a bout for medical
reasons
any one round or evidences inability to control the
position of the head 3. Recommend that the ring physician be authorized to
4. Automatic suspension of any participant who stop any bout in progress, examine a contestant
sustains a knockout, technical knockout, or other and, when indicated, terminate a bout that might
result in serious injury
severe injury for as long as medical consultants feel
is necessary 4. Urge state and local commissions to conduct
5. The universal adoption of the new unapproved frequent medical training seminars for all ring
shock-absorbing ring padding under the canvas and personnel
on the posts of the ring to aid in prevention of 5. No boxing contests should be permitted unless (1)
injuries caused by striking the head against the contest is held in an area with adequate
unpadded surfaces neurosurgical facilities, (2) advanced life-support
6. The required use of headgear to minimize systems are available at ringside, and (3) a
lacerations and contusions, and properly fitted comprehensive evacuation plan exists for the
mouthpieces to protect the teeth and supporting removal of any seriously injured boxer to hospital
tissues facilities
7. Coaching and training of a quality to assure the 6. The condemnation of unsupervised boxing
maximum protection that skillful performance and competition between unlicensed boxers in "tough
man" contests
good condition can provide
7. Mandate the use of safety equipment, s'uch as
8. Referees familiar with, and alert to, the health plastic safety mats and padded comerposts, and
hazards inherent in boxing encourage continued development of safety
equipment
8. Extend all safety measures to sparring equipment
THE AMA ON BOXING 9. Upgrade standardization and strict enforcement of
Historically, the American Medical Association medical evaluations for boxers
(AMA) has expressed its concern about the potential
medical hazards of boxing for over two decades. In
1962, the AMA formed the Committee on Medical ing with less padding in the glove and the prohibition
Aspects of Sports, which was established to address of wrapping the hands to reduce the force of the blow.
the health aspects of boxing and other sports.2 After It was suggested also that the system of point scoring
careful review of the scientific literature, and after be revised to emphasize skillful offensive and defen-
considering the arguments presented by the oppo- sive maneuvering instead of the knockout blow. Re-
nents and proponents of boxing, the committee con- search designed to develop a protective headguard
cluded that the sport of boxing is a debatable and was also suggested.
unsettled issue that could not be resolved easily. Ac- In 1983, the AMA Council on Scientific Affairs3
cordingly, the committee recommended many health established the Medical Advisory Panel on Brain In-
and safety provisions that should be implemented be- jury in Boxing. The panel concluded that to ban the
fore boxing is permitted (Table 1). In addition, 'the sport of boxing was not a realistic approach and rec-
committee also suggested that other potential safety ommended improvements in administrative and
measures be considered. These included experiment- medical standards (Table 2). The council report sup-

408 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 4, 1988
 REFORM IN BOXING

ported the formation of a national regulatory agency TABLE 3. MEDICAL INTERVENTIONS

that would utilize a computer-based central registry RECOMMENDED BY THE UNITED STATES OF
to record the results of all licensed bouts and maintain AMERICA AMATEUR BOXING FEDERATION
IN AMATEUR BOXING
an accurate account of all boxing injuries, including
technical knockouts (TKOs) and knockouts (KOs). 1. Formation of a national regulatory agency, the
This national registry would limit the incomplete and USAABF, to enforce uniform medical standards
fragmentary exchange of information between state 2. One or more physicians must be in attendance at all
or local boxing commissions that exists in professional amateur boxing shows and must be prepared to
boxing. The accurate exchange of information would deal with any emergency that may arise
prevent boxers who were medically suspended in one 3. Contestants shall be thoroughly examined
state from going to another jurisdiction to compete. immediately before and after each bout
Ever since the position statement of the Council
4. A physician may, at his own discretion, enter the
on Scientific Affairs,3 the AMA's position has evolved ring immediately if a bout ends in a knockout or if it
from that of medical reform and safety revisions to is stopped because of an injury
complete abolition of amateur and professional box- 5. The attending physician may suspend a bout at any
ing. On three separate occasions the AMA has voted time if in his/her opinion a contestant is in danger of
for the abolition of boxing.4 These resolutions called further physical injury
for abolition of both amateur and professional boxing 6. Any boxer rendered unconscious or who receives
so as to assist state medical societies and state legis- excessive blows to the head is medically suspended
latures in enacting laws to eliminate boxing. To date,
the AMA continues to support the total abolition of 7. Before resuming boxing, after medical suspension,
all boxing. In addition, other medical organizations, the boxer must undergo a medical examination
such as the American Academy of Pediatrics, the 8. Any boxer that is medically suspended secondary to
American Association of Neurological Surgeons, the head blows is issued a Restrictions Affidavit
American Neurological Association, and the Amer-
ican Academy of Neurology have supported the ab-
olition of boxing in the United States.5 uments the outcome of previous fights and provides
an updated account of the boxer's activities. Presen-
BOXING COMMISSIONS tation of this passport is mandatory before any ama-
teur boxer can participate in competition.
United States of America Amateur Boxing The USAABF also advocates an active role for the
Federation ringside physician. The ringside physician has the au-
The United States of America Amateur Boxing thority to terminate a bout if a boxer is injured or is
Federation (USAABF), the national regulatory at risk of further physical injury. This authority can
agency for all amateur boxing in the United States, be particularly important if the referee fails to rec-
has been instrumental in promoting safety in amateur ognize an injured boxer, or if a boxer is unable to
boxing. The medical interventions of the USAABF, properly defend himself.
a subunit of the United States Olympic Committee,
are listed in Table 3. The formation of the USAABF
is probably the single most important safety factor New York State Athletic Commission
introduced into amateur boxing. The establishment Professional boxing is regulated at the state or local
of this national regulatory agency enables the en- level and lacks a formal national regulatory agency.
forcement of uniform medical standards throughout Accordingly, there are over 40 state or local boxing
the United States.6 Unlike its professional counter- commissions with varying standards of medical su-
part, which lacks a national regulatory agency, the pervision. The NYSAC7 probably is the most strictly
USAABF is more capable of conducting effective medically regulated boxing commission in the coun-
medical surveillance of its boxers. When an amateur try and has been in the forefront of implementing
boxer is medically suspended, the national office is safety measures in professional boxing (Table 4). The
notified, and continued boxing is prohibited. To fur- most important medical intervention of the New
ther prevent a suspended boxer from fighting, the York State Athletic Commission (NYSAC) is the uti-
boxer's "passport" is taken away. The passport doc- lization of neurodiagnostic testing. In addition to a

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REFORM IN BOXING

TABLE 4. MEDICAL INTERVENTIONS IMPLEMENTED TABLE 5. MEDICAL AND SAFETY

BY THE NEW YORK STATE ATHLETIC RECOMMENDATIONS OF THE ASSOCIATION
COMMISSION OF BOXING COMMISSIONS
1. Two ringside physicians at all fights who have the 1. A minimal standard for medical examinations
authority to terminate the fight 2. Develop a nationwide computer network to track
2. Medical Advisory Board that advises the NYSAC activities of professional boxers
regarding medical aspects of boxing 3. All states should develop a boxer passport and
3. Utilization of the thumbless glove enforce its use
4. Mandatory suspension of boxers who loose six 4. All states should attempt to regulate and inspect
consecutive fights boxing gyms
5. Medical suspension for a boxer sustaining a 5. No individual should be allowed to begin training as
knockout or technical knockout a professional boxer without first having a complete
physical examination
6. Mandatory neurological examination, computerized
tomographic scan, and electroencephalogram for 6. All states recognize the medical suspensions of
boxers medically suspended after a knockout or other states
technical knockout 7. All states establish medical advisory boards
7. Annual dilated eye examination by an
ophthalmologist
8. Annual neurological examination; computerized professional bouts in New York State, two physicians
tomographic scan and electroencephalogram who are trained and selected by the NYSAC are re-
quired at ringside. The ringside physician can exercise
the option to terminate a fight if a boxer is injured
detailed neurologic examination prior to obtaining a or defenseless. In addition to the ringside physician,
license to box professionally in New York State, each an ambulance must be on the premises. This will en-
boxer is required to submit to an electroencephalo- sure swift emergency evacuation of an injured boxer.
gram (EEG) and a computerized tomographic (CT)
scan. An abnormal neurodiagnostic test would pre-
vent boxers with subclinical neuropathology from The Association of Boxing Commissions
boxing. Furthermore, it would provide data on the The Association of Boxing Commissions (ABC)
prevalence of CT and EEG abnormalities in active represents the first active attempt by the boxing com-
professional boxers, utilizing a large population base. munity to establish a national regulatory body for
In addition to this annual neurologic evaluation, any professional boxing in the United States. The ABC is
boxer sustaining a KO or TKO is medically suspended a nonprofit organization designed to promote safety
from boxing for a minimum of 45 days and is required in professional boxing.8 Membership in the ABC is
to undergo a neurologic examination, CT scan, and voluntary and is open to the boxing commissions of
EEG before reinstatement. each state of the United States, Puerto Rico, the Virgin
Recently, the NYSAC has also required a complete Islands, the provinces of Canada, and the states of
annual eye examination by an ophthalmologist of all Mexico. Because membership in the ABC is volun-
active boxers. The major advantage of this interven- tary, and because the ABC has no executive authority
tion is the full visualization of the retina. Although over the participating local or state boxing commis-
all boxers undergo a direct ophthalmoscopic exami- sions, the effectiveness of the ABC to regulate profes-
nation prior to all bouts, an indirect funduscopic sional boxing is dependent on the cohesiveness and
evaluation with dilated pupils can detect retinal tears, mutual cooperation of the participating commissions.
holes, or detachment that might be otherwise unde- Thus far, the ABC has been effective in establishing
tected by the ringside physician. To further prevent guidelines for the improvement of boxing and has the
eye injuries, the NYSAC has also introduced the participation of a majority of boxing commissions,
thumbless glove to prevent thumbing injuries to including the more active commissions such as Ne-
the eye. vada, New Jersey, New York, and Texas.
Similar to the USAABF, the NYSAC advocates The medical and safety recommendations of the
active involvement of the ringside physician. At all ABC9 are shown in Table 5. One of the major rec-

410 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 4, 1988
 REFORM IN BOXING

ommendations of the ABC is the establishment and TABLE 6. PURPOSES OF THE UNITED STATES
utilization of the boxer passport system. The passport BOXING COMMISSION
system, along with the development of a nationwide
computer network, would afford a mechanism for 1. Propose rule changes in boxing to ensure the
safety of its participants and establish uniform
the medical surveillance of professional boxers. For rules for state athletic or boxing commissions
identification purposes, each passport would contain
a photograph of the boxer, his name, address, date of 2. Research the causes of boxing-related injuries and
recommend preventive steps
birth, weight, height, hair color, and signature. In ad-
dition, the passport would include the medical record 3. Establish minimum standards and procedures for
and the boxer's history, detailing the outcome of all physical and mental examinations
bouts, and documenting all medical suspensions. It 4. Establish minimum standards for the availability of
is recommended that the boxer's passport be pre- medical services at professional boxing matches
sented at each and every fight. Failure to show the 5. Establish voluntary life and health insurance funds
passport may result in a fine or in a suspension from for professional boxers
the fight. In the event of a medical suspension, it is 6. Establish a national computer system to collect,
suggested that the passport be sent to the governing store, and retrieve medical information and boxing
commission to further prevent the boxer from fighting histories of professional boxers
until the suspension is lifted. 7. Research and establish minimum standards for the
A novel, but necessary, recommendation of the manufacturing and use of boxing equipment
ABC is the regulation and inspection of boxing gyms. 8. Provide a mechanism for the national certification
The rationale for this safety intervention is to reduce of professional boxing assistants, including
the potential for medical injury during training. It is trainers, referees, judges, and ringside physicians
a well-understood fact that the majority of boxing 9. Work with international boxing organizations to
occurs during training. Therefore, it is advisable that establish international standards
sparring be conducted under the safest conditions
possible. The routine inspection of boxing gyms 10. Review existing state athletic or boxing
commission rules and regulations for professional
would enforce the adherence to safety precautions boxing and provide assistance in meeting minimum
and prohibit boxers who are medically suspended health and safety standards
from sparring and risking further injury. The strict
regulation of boxing gyms would also provide a
mechanism to enforce another ABC recommenda- As the national regulatory agency for professional
tion: that no individual be allowed to begin training boxing, the USBC can establish a voluntary life and
as a professional boxer without first having a complete health insurance program for professional boxers. In
physical examination. view of the potential hazards associated with boxing,
a health insurance plan is almost mandatory. Another
function of the USBC is that it could serve as a re-
FEDERAL REGULATIONS source for the medical investigation of boxing-related
,injuries.
Historically, with the exception of the ABC, the
ability of the professional boxing community to reg-
ulate itself on a national basis has been negligible. DISCUSSION
Accordingly, a proposal for the federal regulation of Medical and safety precautions to prevent or man-
boxing is currently in Congress.'0 The Richardson age acute boxing injuries have been well implemented
Boxing Bill (HR 2127) calls for the formation of the in both amateur and professional boxing. The au-
United States Boxing Commission (USBC), a feder- thority granted ringside physicians to terminate a
ally chartered, nonprofit corporation that would reg- bout, the proper medical screening of boxers, and the
ulate professional boxing on a national level. The availability of emergency medical services make the
purposes of the USBC are similar to those of the ABC acute neurologic injury associated with boxing less of
(Table 6). Unlike the ABC, however, the USBC could a medical concern. In modern-day boxing, the em-
exert more authority over the local or state commis- phasis is beginning to shift to the prevention of
sions. chronic neurologic injuries.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 4, 1988 411
REFORM IN BOXING

The prevention of chronic neurologic injury, how- boxing correctly cite the inherent dangers associated
ever, requires epidemiologic research to determine with it, many remain uninformed about the medical
the risk factors. Since chronic neurologic injuries (ie, and safety reforms in the sport of boxing.
chronic traumatic encephalopathy or dementia pu-
gilistica) often occur long after a boxer has ceased his Literature Cited
career, its prevention is difficult. Ideally, this would 1. Jordan BD. Neurologic aspects of boxing. Arch Neurol
require a prospective evaluation of a cohort of boxers 1987; 44:453-459.
over an extended period of time; to date this has not 2. Committee on Medical Aspects of Sports: Statement on
been performed. Currently, a prospective epidemio- boxing. JAMA 1962; 181:158.
3. Council on Scientific Affairs: Brain injury in boxing. JAMA
logic evaluation of amateur boxers is being conducted 1983; 249:254-257.
to determine the long-term effects of boxing on neu- 4. Lundberg GD. Boxing should be banned in civilized coun-
ropsychologic functioning. Although this project will tries-Round 3. JAMA 1986; 255:2483-2485.
5. Morrison RG. Medical and public health aspects of boxing.
not address specifically the chronic neurologic injuries JAMA 1986; 255:2475-2480.
of boxing, it will determine to what extent amateur 6. Official United States of America Amateur Boxing Fed-
boxing is hazardous to the well-being of its partici- eration, Inc. Handbook, 1987.
7. New York State Department of State: Laws and Rules
pants. Currently, it is an unanswered question Regulating Boxing and Wrestling Matches, 1984. Albany, NY:
whether amateur boxing alone can cause chronic New York State Department of State, 1984.
brain damage. 8. Constitution of the Association of Boxing Commissions,
1986.
In response to the medical community's condem- 9. Minutes of the Association of Boxing Commissions Meet-
nation of amateur and professional boxing, the boxing ing, May 16-17, 1986.
community has made several instrumental attempts 10. United States House of Representatives. Richardson
Boxing Bill (HR 2127) Washington DC: Government Printing Of-
to increase medical safety. Although the critics of fice,

412 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 4, 1988