Sports Medicine Rehabilitation in Boxing

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Sports medicine and rehabilitation has taken on greater importance in boxing today. The issues of injury prevention, education and conditioning of athletes, and the treatment of injuries- fractures, dislocations, intracranial bleeds are of major importance within the sport of boxing.

Proper assessment and treatment of boxing injuries require an understanding of boxing specific musculoskeletal and neurological injuries.

The value of an inter disciplinary approach to boxing to include physical therapists, massage therapists, certified fitness trainers and nutritionalists is important to the approach of providing comprehensive health care to the boxer athlete.

The mission of sports rehabilitation is to rehabilitate the injured boxing athlete beyond the resolution of symptoms in order to allow a medically safe return to the sport and prevent further injury.

Physician

The ringside physician is a physician licensed in medicine who has a broad understanding of common boxing injuries as well acute emergencies. Ringside physicians are presently participating on a voluntary basis.

The role of the ring physician is to ensure the participant safety and ability to perform in this contact sport. A background in sports medicine is an attribute for a ringside physician.

The preferred physician should be a medical doctor or doctor of osteopathic medicine and have proof of a current medical license as well as medical malpractice insurance. He should be able to be in good standing at a local hospital and familiar with the nearest hospital emergency room to the boxing arena.

Communication between the local emergency medical trauma team and the ringside medical staff is critical in managing acute life-threatening injuries.

Rehabilitation

Boxing injuries can be divided into two basic types- those resulting from acute trauma and those resulting from chronic repetitive microtrauma. Each type of injury has certain specific characteristics and findings that are associated within the evaluation process.

The difference between acute and chronic injuries lies in the fact that acute injuries occur from a one-time event and are easily recognizable, whereas chronic injuries usually present as a gradual onset with increasing symptoms. In the chronic injuries, the exact timing of the onset of injuries usually less exact since symptoms may be more widespread and may be initially easily overlooked.

For both types of injures rehabilitation is an important process that promotes healing and restoration of functional capabilities. Principles of Rehabilitation There are three major phases that exist in the rehabilitation process: the acute, the recovery, and the maintenance phases.

The goal of rehabilitation includes the return of tissue healing, maintenance of fitness, resolution of the injury cycle, and restoration of functional endurances and flexibility to return back to the sport.

In the acute phase of rehabilitation modalities should be used to reduce the signs of acute inflammation and injury. Modalities such as ice, heat, hydrotherapy, electrical stimulation work to decrease the swelling and facilitate tissue healing. Anti-inflammatory medications, splinting and surgical treatment are all utilized in this phase of rehabilitation.

Recovery Phase of Rehabilitation

The recovery phase is often the most lengthy and most involved phase of rehabilitation.  Emphasis in this stage shifts from resolution of clinical symptoms to restoration of function. Anti-inflammatory medication and physical therapy modalities are use much less frequently and assume a more adjunctive role.

Appropriate tissue loading is the major modality that is used in this phase. As tissues regain their integrity, flexibility is increased and strength improved through isometric and isotonic exercises and then isokinetic rehabilitation. 

Isometric exercise increases strength quickly essentially through no movement, (i.e., pushing against a wall). The disadvantage of isometrics is that strengthening does not occur through the full range of motion, therefore flexibility and conditioning are not promoted.

Isotonic exercise promotes muscle conditioning through movement. Calisthenics and weightlifting are common examples of isotonic exercises. In isotonic strengthening, muscles are loaded with increasing increments to promote both strength and endurance.
The disadvantage of isotonic exercises is that these exercises are not specific in promoting cardiovascular fitness. 

Isokinetic exercise promotes strengthening and flexibility through a range of motion for which a maximal force is given at every point within this range of motion. Isokinetics frequently involve specialized machines that match the strength through every degree of motion. This form of strengthening and exercise is very effective for it provides a constant load on the muscle allowing the athlete to achieve the highest level of performance. 

An adjunct to isometric, isotonic and isokinetic exercise strengthening program is aerobic fitness. Aerobic exercises improve cardiovascular fitness by increasing the heart rate, which promotes positive physiological changes on the cardiovascular and respiratory systems.

Aerobic exercise should be targeted for a minimum of 15 minutes to increase the heart rate within the desired target training level.  In addition to modalities and exercise, the therapist may add to their rehabilitation, regimen using assistive devices.

Taping, braces and splints are frequently utilized in acute trauma. Therapeutic massage has also been utilized as a modality in acute injuries. Massage has been shown to be beneficial in improving the stretching of tendons and connective tissue providing relief of muscle tension and spasm. Massage enhances muscle recovery from intense exercise as it improves muscle blood flow.

Recovery Phase of Rehabilitation

The recovery phase is usually the longest and most involved phase of rehabilitation. The emphasis of this phase is the resolution of clinical symptoms and restoration of function.  Within this stage, anti-inflammatories and modalities are much less frequently utilized. 

As recovery of muscular tissues is achieved, strength and flexibility are the focus of the rehabilitation. Concentric and eccentric muscle strengthening as well balance are emphasized.

Maintenance Phase of Rehabilitation

The maintenance phase is the final phase of rehabilitation and helps prevent future injury. In this phase, the athlete is prepared to return back to his level of athletic performance.  Simulated activity within the sport's specific motions should be evaluated for any weaknesses and strength, lack of flexibility or pain.

Protective equipment should be used to prevent any recurrent or new trauma during this phase of rehabilitation. Criteria to return back to athletic ability and training should be strict and include the following components: no pain, full range of motion, strength being equal on opposite sides, strength balance within the expected norm for the sport, and a completion of the functional interval progression of activities.

Acute Exacerbation of Chronic Injury

Acute exacerbation of chronic injury is difficult to distinguish from acute injuries. An athlete may assume that the injury was completely healed and then, through activity, have an acute exacerbation. It is up to the healthcare practitioner to differentiate between a new trauma and a re-aggravation of an underlying chronic condition.

Treatment of the acute episode overlying a chronic problem involves the same recovery phases as acute injuries. Identifying specific anatomical or physiological trauma is more importantly the key to minimizing the degree of permanent injury.

Common Boxing Injuries at Olympic and Amateur Level

A 15-year record of injuries and illnesses of amateur boxers at the Untied States Olympic Training Center in Colorado Springs was reviewed by Dr. Timm, et al. (2). Although there were significant differences between the frequency of injuries and illnesses collectively, the serious injuries represented only a relatively small percentage (6.1 %).

The most common involved the upper extremity representing 25%, second most common were head and face injuries, representing 19%, third were lower extremity injuries, representing 15% and finally spinal column injuries representing a 9% incidence.

This study, followed by Dr. Timm, found the most common injury was a contusion representing 24.90/0, followed by muscle strains representing 20.8%, joint strains 17.5%, tendonitis 9.2%, concussion 6.1 % and fracture 4.9%.

The probability of injuries recurring is great if the athlete returns prior to completing rehabilitation. In order to ensure a safe recovery, five criteria should be met before participating in full physical activity: I) Absence of pain; 2) Full range of motion at the injured area; 3) Normal strength and size of the injured area; 4) Normal speed and agility; 5) Normal level of fitness.

Absence of pain

In the acute phase of injury, pain usually disappears within a few days for a bruise or minor sprain. For more serious injuries, the pain may remain for days or weeks. The main goal of rehabilitation is to resolve pain, reestablish normal range of motion, strength and power and muscular endurance at the site of injury.

Full range of motion

Musculoskeletal injuries reduce range of motion at the joint. The more severe the injury, the greater loss of range of motion. As soon as the athlete is able to move an injured area, the athlete should be encouraged to progressively increase the range of motion until normal range is achieved.

In regards to appropriate stretching over the past two decades, many experts have advocated prolonged stretching anywhere from 30 seconds to 20 minutes for what was termed the optimal stretch. For years, this prolonged static stretching technique was the standard.

However recently, studies have shown prolonged static stretch greater than five seconds actually decreases the blood flow within the tissue creating localized ischemia, increased lactic acid buildup and lymphatic stasis.

With appropriate isolated interval stretching, full range will eventually return. When an athlete can move the injured muscle or joint through its normal range, strengthening exercises should begin.

Muscle strength and size

After an injury, muscle disuse or atrophy occurs from splinting, wrapping, and resting the affected muscle groups. As a result of disuse, muscles become smaller and weaker than they were before the injury. Strengthening of the injured muscle group should be done conservatively and with weighted increments. Weights should be incorporated to a level of pain tolerance. If the weight utilized creates significant pain levels, then one should return back to a lighter weight for the strengthening program.

Assessing full strength and size is best when compared to the uninjured area on the opposite side of the body. When both areas are equal size and strength, then the athlete may progress to the next phase of recovery, which is competitive practice.

Speed and agility

Once the athlete has regained full strength through the entire range of motion, he is ready to return to practice competition.  Returning to practice, the athlete progresses with the intensity and duration of the activity.  It is important for the trainer to specifically monitor
and observe the previously injured body part.  When an athlete can move at a pre-injury speed and agility, he is potentially ready to compete again.

Level of fitness-conditioning

Fatigue and injury have a strong relationship. When an athlete becomes fatigued, his skill performance is reduced. Concentration becomes more difficult, and reaction times slow down. As the athlete's judgment becomes impaired, faulty decisions are made which result in injuries.

One of the final phases of sports medicine and rehabilitation is to improve performance and conditioning. The conditioning program is designed to minimize fatigue and potential for injury. Similarly, coaches and trainers must be aware that athletes will engage in intense, frequent practices and bouts. They athletes require time off. It is possible to over-train and cause, rather than prevent, injuries.

Injuries caused by overtraining are at an increasing proportion within all sports injuries. Signs and symptoms of overtraining and potential for injuries include: .elevated resting heart rate .chronic muscle soreness .poor performance .higher incidence of injury .longer time to recover from injury Warm-up. 

The body responds optimally when proper physiological responses are coordinated. The body requires a controlled warm-up period to prepare itself physiologically with optimal body temperature, increased blood flow and neurosensitization. This physiological response promotes greater tissue pliability with more effective and efficient neuromuscular functioning.
 

Cool-down Period

Muscles in the body tighten during periods of inactivity following hard work. To minimize muscle stiffness and the soreness, 20 minutes should be dedicated to adequately cool down at the end of the practice. A gradual reduction of activity (the reverse of the warm-up procedure) facilitates removal of the body's waste products associated with intense muscular activity.

Bibliography

1. Ylinen J., Cash M., S12orts Massage, London: Stanley Paul, 1988.

2. Timm K., Wallach J., Jo:ymal of Athletic Training, Vol. 27 No.4, 1993, pp. 330-334.

3. Estwanik J.J., Boitano M., Ari N., Amateur Boxing Injuries at the 1981 & 1982 U.S.A./A.B.F. National ChamRionshiRS. Physical Sports Medicine, October 1984; 12: pp. 123-128.

4. Jordan B.D., Voy R.O., Stone J, Amateur Boxing Injuries at the U.S. Olympic Traing Center, Physical Sports Medicine. February 1990; 18: pp. 81-90.

5. Ross R. T., Ochsener M.G., Jr., Boyd C.R., Acute Intracranial Boxing-Related Injuries
in U.S. Marine Qom Recruits: Re}2Qrt of Two Cases. Mili Science, January 1999; 164 (1): pp. 68-70.

6. Saengsirisuwan V., Phadungkij S., Pholpramool C., Renal & Liver Functions and Muscle Injuries during Training and after Competition in Thai Boxers, British Journal of Sports Medicine, December 1988; 32 (4): pp. 304-308.
Majjoni M.C., Skalak T .C., Schmid-Chonbein L. W., American Medical Journal of
Physiology, 1990, Section: 259 (6 Pt2); pp. 1860-1868.
 

Should you have any further questions regarding this article, please direct your questions or comments to "Ask the Doctor" section.

Copyright © 2004 - 2010 Taras V. Kochno, M.D.  All Rights Reserved
Board Certified in Physical Medicine and Rehabilitation

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