“You wanna fight? You damn stupid fool,” says Jackie Gleason’s character, trainer Maish Rennick, to Louis “Mountain” Rivera (played by Anthony Quinn) in the 1962 film “Requiem for a Heavyweight.”
“Don’t you understand? The odds are, all you’ll wind up is a mumbling idiot — a stuttering jerk. Why don’t you go home?”
Dr. Anthony Alessi, UConn Health associate clinical professor of neurology and orthopedics and director of the UConn NeuroSport Program, has been giving fighters similar messages, albeit more tactfully phrased, for the last 21 years as the consulting neurologist during boxing matches at Mohegan Sun. He has gone on to study head trauma in other sports, how to measure recovery, how to gauge when an athlete is ready to return to play, and how to prevent head injuries. But he got his start as a “fight doctor.”
After working as an athletic trainer at Mount St. Michael Academy in the Bronx, Alessi eventually opened a neurology practice in Norwich, Connecticut. He started working with the Yankees’ Double-A team, and noticed during his hospital shifts that he was looking at many baseline, prefight brainwave EEGs for boxers on the cards at Mohegan Sun casino.
“The Connecticut boxing commissioner invited me to come down to watch a fight,” Alessi says. “After the fight, he said, ‘How would you like to work with us?’ I said, ‘Do I get to end the fight?’”
“He said, ‘We want you to.’ I’ve been ending fights since 1996.”
There’s no such thing as a minor concussion. And as I tell students, if you’ve seen one concussion, you’ve seen one concussion. They’re all different.
Alessi admits it’s odd for a neurologist to work in a sport where the entire goal is to induce maximum cognitive impairment in your opponent — but that’s exactly what makes his presence imperative.
“In mixed martial arts, you have the ability to tap out,” Alessi says. “In boxing, they can’t quit. But you’d be surprised how many times you go into the corner and the fighter doesn’t want to come back out. That’s the first question I ask them, and if they say no, I end the fight. He’ll still get paid, and I’ve saved his life.”
The American Academy of Neurology has backed off from its edict in the 1980s that boxing should be banned, instead calling for measures including more regulations and formal neurologic examinations for fighters. Alessi says more and more neurologists have gotten involved in the sport, screening individuals to determine whether they should fight.
Besides protecting individual athletes, Alessi has used boxing as a lens through which to view the larger picture surrounding head trauma.
“As the public awareness about long-term brain damage from concussions developed, I realized it was like I had my own lab,” he says.
More to Learn
The world has known for a long time about the dangers of head trauma, the syndrome codified in 1928 when New Jersey forensic pathologist Dr. Harrison Stanford Martland published a paper in The Journal of the American Medical Association on fighters and coined the term “punch drunk.”
Today, it seems that new findings on head injury are in the news daily. Since 2001, more than 60,000 scientific papers on chronic traumatic encephalopathy (CTE) and brain trauma have been published, raising awareness at both the public and professional levels, leading to protocols where athletes are pulled from games at the first sign of concussion. Trainers are taught to perform a SCAT5 (Sport Concussion Assessment Tool, 5th edition), elaborating on the questions the old cigar-chomping cornermen used to ask fighters between rounds: “What’s your name? What day is it? Do you know where you are?”
The SCAT5 is used because the greatest and most immediate danger to concussion sufferers is second-impact syndrome, a fatal edema caused by a second head trauma sustained before the brain has had time to repair torn tissues, ruptured blood vessels, or damage at the cellular level from an earlier injury. Other organs have room to expand if they swell. The brain, encased in a hard shell, does not.
“There’s no such thing as a minor concussion,” says Alessi, who teaches at the UConn School of Medicine. “And as I tell students, if you’ve seen one concussion, you’ve seen one concussion. They’re all different. In most cases, a single concussion should not cause permanent damage, but a second concussion, soon after the first, does not have to be very strong for its effects to be permanently disabling or deadly.”
The problem with studying concussions is that you can’t line up a variety of test subjects of various ages and sizes, take baseline measurements, and then hit them in the head with a 13-pound bowling ball moving 20 mph — the equivalent, experts estimate, to taking a punch from a pro boxer. You can’t then compare those results to the results from hitting them with 6-pound bowling balls moving 40 mph, or to what the results would be if you hit them once an hour, or once a day for a month, or in the side of the head instead of the front.
“Ninety percent of the time, after a concussion, you wait 10 days and the athlete is going to be okay. But we still don’t know what the long-term effects might be. We know how the cells repair themselves, but we don’t know what kind of debris might be left behind once the cells heal,” Alessi says.
In July, Boston University released the results of a study of the brains of 202 deceased football players, 111 of whom had played in the NFL. All but one of the NFL players’ brains were found to have CTE.
Alessi is, of course, aware of the current discussion of CTE in relation to professional sports, but he attends from a scientist’s detached distance.
“There’s an association with football, but it doesn’t mean there’s causation. It’s an important difference. There’s a lot of selection bias.”
Those who donate their brains, Alessi says, may be looking for a biological explanation for their depression, for example.
Alessi is more concerned that attention is being paid in the wrong places.
“It’s a pyramid,” he says. “There are only 1,800 professional football players. In college football, there are 54,000. In high school football, about a million. In youth football, you have over 3 million children. Another 3 million children play youth soccer, and a half million play youth hockey. So you have 6.5 million young athletes playing high-velocity collision sports, all with brains that are still developing.”
Children lack both the myelin sheathing that protects older brains and the developed neck musculature that helps older athletes avoid injury. In addition to working with UConn student-athletes and teams, Alessi advises youth sports programs and is concerned for the younger athletes.
“They’re smaller and they don’t move as fast, so the force of impact is less, but they’re more vulnerable,” Alessi says. “We used to think if you let kids play full-contact sports, it will toughen them up — not true. The more contact you have, the greater the risk.
“There’s also inadequate medical attention at those levels,” he says. “We’re not paying attention to where our resources should be placed the most.”
The Korey Stringer Institute (KSI), a national sports safety research and advocacy organization based at UConn, recently urged state high school athletic associations to implement life-saving measures after KSI conducted the first comprehensive state-by-state assessment of high school sports safety polices. Each state received a score based on the extent to which it met best- practice guidelines addressing the four leading causes of sudden death among secondary school athletes, which include head injuries.
Requiring the presence of certified athletic trainers at every secondary school athletic event and training coaches on concussion symptoms are among the bare-minimum guidelines, which are endorsed by leading sports medicine organizations in the United States.
Still, progress has been made.
Banning checking and headers in youth hockey and soccer and reducing full-contact practices to once a week for professional and college football have been linked to reduced injuries, Alessi says. But many youth football teams still have full-contact practice five days a week.
No one wants collision sports to go away, Alessi says, but instead of striving to play harder, he believes we can strive to play smarter.
“You have to ask, what’s to be gained from high-velocity impact at a young age? The fastest-growing youth sport in America today is flag football. Archie Manning [former pro-football quarterback and father of Peyton and Eli Manning] didn’t let his sons play youth football. Tom Brady never played youth football. A lot of really good professional athletes in the NFL knew that they could build skill without getting hit,” Alessi says.
“I think there’s a lot to be gained by us changing the rules. We’ve made a lot of headway with all neurologic injuries in sports. Legislation isn’t required to deploy common sense.”
Thanks to the work of Alessi and people like him, athletes know the risks before they step on the field or in the ring. While there’s always more research to be done, at the very least, we’ve replaced the comical cartoon image of the cross-eyed concussion victim — with the lump rising from his noggin and stars and birds circling his head — with reliable information. The kind of information an athlete in a collision sport needs to make informed decisions and to play safely, avoiding injuries when possible and returning to play only when it’s safe to do so.
“If you gotta say anything to him,” Maish Rennick says of “Mountain” Rivera at the end of the movie, “tell him you pity him. Tell him you feel so sorry for him you could cry. But don’t con him.”