Ali – a review for healthcare staff
(See also what the International Movie Database says about Ali)
Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.
Theme: THE BRAIN AND BOXING
– The soul of a butterfly and the injuries it can sustain
By Henrik Zetterberg, Associate Professor, Chief Physician, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, and Laboratory of Clinical Chemistry, Sahlgrenska University Hospital
In the 2001 film "Ali", we get to meet one of boxing's true icons, Muhammad Ali. He was born Cassius Marcellus Clay, Jr., on 17 January 1942, and was named after his father, who in turn had been named after the 19th Century politician and opponent of slavery, which was of great symbolic value in the family. In 1964, Clay changed his name to Muhammad Ali after joining the Nation of Islam and converting to Islam.
Clay began boxing as a 12-year-old. He was clearly talented and won the Olympic gold medal in the light heavyweight division in 1960 in Rome. He won his first professional fight at the age of 18. This was the start of a remarkable career, and between 1960 and 1963 he was involved in a total of 19 bouts. He won all of them, including 15 by knockout.
Clay’s boxing style was unorthodox. He was 1.91 m tall, extremely quick and often lowered his guard. One of his signature moves was "dancing away" when his opponent attacked. But he took a great deal of punishment.
In 1963, Clay won a much-discussed fight against Doug Jones, who caught him with a head shot early on which affected Clay's ability to defend himself throughout the bout. In the same year, Clay was knocked down by a left hook by Henry Cooper. He managed to collect himself, however, and inflicted a cut on Cooper which led to the match being stopped in the fifth round.
All of these wins resulted in a title bout against the reigning heavyweight champion, Sonny Liston, on 25 February 1964 in Florida. This is where the film starts. Before the fight against Liston, another of Clay's characteristics became clear to the general public in the USA: excessive psyching out and verbal attacks during the weigh-in.
Clay was not afraid of claiming victory in advance. One of his gimmicks was to predict the round in which he would stop his opponent. He called Liston "the big ugly bear" and said that to win the fight he would "float like a butterfly and sting like a bee". Liston wouldn't be able to get near him: "Your hands can't hit what your eyes can't see". Numerous examples of Clay’s verbal fluency can be found on YouTube.
The fight is realistically portrayed in the film, and to the surprise of many Clay emerged the victor. In the return match a year later, Liston was knocked out in the first round in what was considered by many boxing experts to be a "rigged" fight. Between 1965 and 1967 he defended his title 9 times, which is more title fights than any other world champion in such a short time.
The cinema version of "Ali" focused on the fight scenes, although prior to the release of the DVD version, the film's director Michael Mann re-cut the film, removed a number of fights and added 30 minutes focusing on political developments in the USA in the 1960s and 1970s, and the role played by Clay.
In 1964, Clay failed the military draft due to his sub-par writing skills. The test was re-examined in 1966 ahead of the draft for Vietnam, and Clay passed. However, he refused to attend military service, citing the Koran. In addition to this, he publically stated that, for him, the American state was a greater enemy than the Vietnamese: "No Vietcong ever called me nigger".
He refused to be known by his "slave name" Cassius Clay, and instead started using the name Muhammad Ali in consultation with his teacher at the Nation of Islam, where Malcolm X was initially a good friend and role model.
All of this resulted in many turbulent years for Ali. In 1967 he was stripped of his world title. He was not allowed to box in the USA, although fights could be arranged overseas. He was prosecuted for conscientious objection, sentenced in several courts to 5 years imprisonment, although his conviction was finally reversed in 1971 with reference to freedom of religion.
Ali ended up in economic difficulties, with old friends in the boxing world abandoning him when he was no longer able to bring in money. In parallel with this he had a family, although family life was coloured by extramarital affairs.
Ali's great comeback came in 1971, when he met Joe Frazier in the classic boxing arena of Madison Square Garden in New York. Ali was floored in the 15th and final round, but he was not knocked out. Frazier won the match on points. In January 1973, Frazier lost his world title to George Foreman. After beating Frazier on points, Ali qualified to meet Foreman. The match was staged in Kinshasa, Zaire, on 30 October 1974, and was arranged by the controversial boxing promoter Don King.
Foreman was the overwhelming favourite. The match is depicted as a cliff-hanger in the film. Ali boxes passively, does not manage to dance away, takes many hits, but in round 8 is able to knock out an exhausted Foreman. This is where the film ends. But what actually happened then?
Ali defended his world title four times in 1975. Several of these bouts were extremely tough. In 1978 he lost the title to Leon Spinks. In an interview before the fight (http://www.youtube.com/watch?v=YkXlBwXai_k&feature=related) his speech is noticeably slurred, although there is no lack of intellectual sharpness.
He is only 36 years old, yet the interview clearly shows suspected signs of the severe neurodegenerative illness that he would suffer from in later life.
In another, otherwise extremely enjoyable interview in 1978, he speaks openly about his anxiety regarding his slowed boxing reflexes (http://www.youtube.com/watch?v=1LQq3ptt8ng).
Six months later, Ali took his revenge and became the champion for a third time. A year later he relinquished his title and retired. In 1980, however, he challenged the new champion Larry Holmes in a fight which Ali's trainer stopped after 11 rounds. He attempted another comeback in 1981, this time against Trevor Berbick.
YouTube clips show an ageing Ali who has lost his characteristic speed, taking a great many shots to the head (http://www.youtube.com/watch?v=TpY2wunOOuY&feature=related). However, he manages to stay on his feet and loses the fight on points.
Ali was diagnosed with Parkinson's disease in 1984. This particularly affected his speech and motor function. He is now wheelchair-bound and is basically unable to speak. It is impossible to prove that it was boxing that caused his brain to be so severely damaged, yet he clearly meets the clinical criteria for chronic traumatic brain injury in boxers (CTBI -B), see fact box (1).
None of this is dealt with in the film. The film admittedly depicts dirty money, treacherous friendships and other less clean aspects of boxing, but does not cover the fact that
"It is extremely difficult to predict which fights will have a fatal outcome"
Ali himself and many of his colleagues sustained severe brain injuries. A cerebral haemorrhage ended Trevor Berbick's (not particularly successful) career. Ingemar Johansson, Floyd Patterson and Emile Griffith all suffered serious dementia. The last of these three also has the dubious honour of killing an obviously defenceless opponent, Benny Paret, in a repulsive title fight broadcast on television in 1962 (http://www.youtube.com/watch?v=vBNQNwCyYqk).
CTBI -B has affected a long line of boxing stars: Jimmy Ellis, Bobby Chacon, Jerry Quarry, Mike Quarry, Wilfred Benitez, Willie Pep, Freddie Roach, Sugar Ray Robinson, Billy Conn, Fritzie Zivic and Meldrick Taylor all appear to have suffered from this form of brain disease.
The reason why Ali continued boxing long after he had lost his winning speed is not covered in the film either. When asked directly by journalists why he was taking the risk of continuing, Ali answered simply: Money and pride.
The brain and boxing
The primary aim of boxing is to strike the head of your opponent so accurately and so hard that he suffers an acute brain injury that leads to unconsciousness, whereby the match is won by knockout.
The difference between a brain injury that leads to a knockout and a more serious brain injury that leads to the death of the opponent is minute. Repeated blows to the head also lead to brain injuries that are initially subclinical, but that reduce the brain's reserve capacity to withstand age-related nerve cell loss. Brain injuries from boxing are divided into acute and chronic, and this is probably also true for other martial arts where blows and kicks to the head are allowed.
Acute brain injuries from boxing
Acute brain injuries include subdural haematomas and cortical contusions. Haemorrhages of this type can lead to the death of the boxer. Over the past ten years, more than 80 boxers, including 24 amateur boxers, have been killed by their opponents (http://ejmas.com/jcs/jcsframe.htm).
A recently published study shows that it is extremely difficult to predict which fights will have a fatal outcome. This is a problem, not only for judges and ringside doctors, but also for medical experts within Kampsportsdelegationen (a Swedish martial arts federation), who decide whether or not martial arts fights can go ahead in a medically safe manner.
The problem of deaths in the ring also highlights an ethical dilemma. In October 1983, the World Medical Association (WMA) agreed on the following statement: "Boxing is a dangerous sport. Unlike most other sports, its basic intent is to produce bodily harm in the opponent. Boxing can result in death and produces an alarming incidence of chronic brain injury. For this reason, the World Medical Association recommends that boxing be banned."
The intention of the sport is to harm your opponent. That means that it differs from other sports that are much more dangerous as regards the number of deaths, such as Formula 1 racing and riding.
So shouldn't doctors distance themselves from boxing and similar sports? Not necessarily, according to the WMA. Until the goal of a ban is achieved, the medical profession should, according to the WMA, work actively to reduce the risks to boxers. This recommendation may explain the work of the Kampsportsdelegationen and ringside doctors in Sweden today.
The fact that the ban on professional boxing in Sweden was lifted in 2006 may seem difficult to understand in the light of the WMA's recommendations. The decision was preceded by discussions about the fact that boxing could otherwise become an even more dangerous underground movement, and that Swedish boxers would be forced abroad to box under less safe conditions there.
To the best of my knowledge, there have been no serious boxing incidents in Sweden since the new rules were introduced in 2006. However, the change in the law has been followed by noticeably greater interest in boxing in Sweden, with a clear increase in the number of members of boxing clubs.
On TV4 Sport, it is also common nowadays to see boxers be knocked unconscious, for example in the Löfbergs Lila arena in Karlstad. A knockout, where the boxer falls unconscious to the floor after a blow to the head, is classed as an acute brain injury.
This unconsciousness is due to the shaking of the brain caused by the blow, which results in an immediate, significant disruption of nerve cell function. From a neurochemical perspective, there is an abrupt release of excitatory neurotransmitters, disrupted glucose metabolism and an uncontrolled flow of potassium from the cells, which is both caused by and triggers further nerve cell death (3).
Chronic brain injuries from boxing
Chronic brain injury in boxers, known as "punch drunk syndrome", was described in 1928 by Martland (4). Millspaugh later coined the term dementia pugilistica for the same condition (5). In modern literature, the terms "chronic traumatic brain injury in boxers" (CTBI -B) and "chronic traumatic encephalopathy" (CTE) are used synonymously.
The symptoms include speech difficulties, disturbed balance, Parkinson-like motor function symptoms, memory problems and impaired attention (6), see fact box. The brains of boxers can demonstrate neuropathological deposits in the form of neurofibrils, particularly in the surface layers of the neocortex, from as early as the age of 20 (7-9). Neurofibrils are otherwise primarily seen in conjunction with Alzheimer’s disease.
The prevalence of CTBI -B stands at approximately 20% in professional boxers, but is very low in amateur boxers (1, 10). A prospective study of amateur boxers was not able to determine any neuropsychological deterioration over a nine-year period (11).
The difference in the prevalence of CTBI -B between professional and amateur boxing is probably a direct effect of the rules in amateur boxing, which are intended to reduce the risk of brain injuries, in particular the shorter number of rounds and the active intervention of the judges to halt uneven matches.
However, there is still worrying data as regards brain injuries in amateur boxing. One study carried out by our group on 14 amateur boxers, where cerebrospinal fluid samples were taken after fights and after a summer break, showed that boxers who had taken more than 15 head shots or individual symptom-causing (dizziness, unsteadiness, double vision) blows demonstrated clear rises in the brain injury proteins neurofilament light (NFL), tau and Glial fibrillary acidic protein (GFAP) in their cerebrospinal fluid (12).
The levels of NFL had risen to the same level that we see in patients after minor cerebral infarcts. After a summer break from fighting, the levels fell although they did not normalise completely. The study provides strong evidence that nerve cells, and in particular their long subcortical axons, are damaged during amateur boxing, even in the absence of knockouts. The effect of nerve cell damage in the long term is unknown, and further research is required, both in order to verify acute brain injury during amateur boxing and to establish any clinical late effects.
Another worrying result has emerged from a team of Turkish researchers, who found a very high prevalence (47%) of growth hormone deficiency in retired amateur boxers (13). The underlying cause is believed to be wear damage to the pituitary stalk in conjunction with repeated blows to the head, and the research team recommends that boxers should be screened for this endocrine disorder and offered substitution treatment if growth hormone deficiency is established.
To sum up, there are clear epidemiologic, neuropathologic and biologic indications that boxing leads to brain injuries. The injury mechanisms are not specific to boxing, of course, but are also relevant to other sports in which repeated skull trauma occurs. In the USA, there is currently an intense debate about new research results that indicate a raised risk of dementia in individuals who play American football (http://www.nytimes.com/2009/09/30/sports/football/30dementia.html).
To go back to the film: Muhammad Ali is clearly one of the most fascinating sports stars of our time. He has a unique boxing career behind him. Unfortunately it was too long and too hard, which we do not get to see in the film. However, what the film does show is an incredibly fascinating, strong personality who took a stance on the rights of African-Americans, on religious freedom, against the Vietnam War, and who was not afraid to accept the consequences of his actions.
Despite his illness, Ali has continued to be involved in the fight against racism and social injustice during the 2000s. In 2004 he wrote the book "The soul of a butterfly" together with one of his daughters. A large section of the book deals with Ali's religious beliefs. I would like to conclude my account with Ali's own view of this controversial sport. The quote below is an example of this boxer's luminous ability to put thoughts into words and his capacity to deliver one-liners:
"It's just a job. Grass grows, birds fly, waves pound the sand. I beat people up."
References
Biographical details about Muhammad Ali have been taken from the following Internet sources:
A large number of Muhammad Ali clips can also be found on YouTube: http://www.youtube.com/
Scientific references:
- Jordan BD. Chronic traumatic brain injury associated with boxing. Semin Neurol 2000; 20: 179-185.
- Miele VJ, Bailes JE. Objectifying when to halt a boxing match: a video analysis of fatalities. Neurosurgery 2007; 60: 307-315; discussion 315-306.
- Giza CC , Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train 2001;36: 228-235.
- Martland H. Punch drunk. Jama 1928; 91: 1103-1107.
- Millspaugh J. Dementia pugilistica. United States Naval Bulletin 1937;35: 297-302.
- Blennow K, Popa C, Rasulzada A, Minthon L, Wallin A, Zetterberg H. [There is strong evidence that professional boxing results in chronic brain damage. The more head punches during a boxer’s career, the bigger the risk]. Lakartidningen 2005; 102: 2468-2470, 2472-2465.
- Corsellis JA, Bruton CJ, Freeman-Browne D. The aftermath of boxing. Psychol Med 1973; 3: 270-303.
- Geddes JF, Vowles GH, Robinson SF, Sutcliffe JC. Neurofibrillary tangles, but not Alzheimer-type pathology, in a young boxer. Neuropathol Appl Neurobiol 1996; 22: 12-16.
- Roberts GW, Allsop D, Bruton C. The occult aftermath of boxing. J Neurol Neurosurg Psychiatry 1990; 53: 373-378.
- Mendez MF. The neuropsychiatric aspects of boxing. Int J Psychiatry Med 1995; 25: 249-262.
- Porter MD. A 9-year controlled prospective neuropsychologic assessment of amateur boxing. Clin J Sport Med 2003; 13: 339-352.
- Zetterberg H, Hietala MA, Jonsson M, et al. Neurochemical aftermath of amateur boxing. Arch Neurol 2006; 63: 1277-1280.
- Tanriverdi F, Unluhizarci K, Kocyigit I, et al. Brief communication: pituitary volume and function in competing and retired male boxers. Ann Intern Med 2008; 148: 827-831.
Published on CNSforum 12 Jul 2010