Float Like a Butterfly, Sting Like a Bee

Dr. Joshua Gatson is working to identify biomarkers that can detect early changes in the brain after a boxing-induced concussion

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By Susan Kirtz, MPH
Managing Editor, Texas Health Journal
Director of Special Projects, Center for Health Communication
The University of Texas at Austin



Muhammad Ali once vowed to “float like a butterfly and sting like a bee.” The second half of his statement is less often quoted: “his hands can’t hit what his eyes can’t see.”

Boxers, among many other types of athletes, are particularly susceptible to traumatic brain injuries (TBI) including concussions, resulting from repeated blows to the head during a match. However, the results of a TBI are not always immediately visible, making it difficult for athletes, coaches, and healthcare professionals to identify and address what their “eyes can’t see.”


Dr. Joshua Gatson, Assistant Professor in Surgery and Neurological Surgery at the UT Southwestern Medical Center is working to identify TBI immediately after it happens. He and his team aim to facilitate better individual and clinical treatment decision making in the moment and in the hours, days, weeks, and years following TBI.

In 2012, Gatson was awarded a research grant from the US Army to study brain biomarkers that help detect early changes after a sports concussion. To do this, he engaged groups of amateur and professional boxers to participate in a fascinating study.

“Boxers receive a number of blows to the head, making them a good model to study the before and after changes within each athlete,” said Dr. Gatson.

Before each match and immediately (five to thirty minutes) after, Gatson and his research team collected extensive data from and about the boxers, including number of blows to the head during the match, blood samples, symptom scores using the Rivermead Post Concussion Symptoms Questionnaire, and in some cases neuroimaging such as an MRI. They were looking for measurable indicators—biomarkers—of early physiological changes after TBI.

They discovered that a particular enzyme, creatine kinase brain (CKBB), was elevated in the normal circulation of boxers who had endured blows to the head. CKBB is typically found only in the brain. If it’s detected at certain levels in the blood, it means that the blood-brain barrier has been compromised as a result of a head injury.

After a boxing match, Gatson was able to measure a dramatic increase in CKBB in the boxers’ blood compared to a healthy, non-injured control group. In fact, the increase was closely correlated with other symptoms seen in post-concussion individuals.

“We identified that CKBB is a very sensitive and specific marker for around 5 minutes after injury. It correlated well with the number of hits that the boxers suffered to the head, as well as the symptom scoring,” explained Gatson.

Survivors of TBI can experience effects lasting hours, days, months, or the rest of their lives. Effects can include impairments in cognitive function (attention, memory, and reasoning), sensation (hearing, vision, impaired perception and touch), motor function (extremity weakness, impaired coordination and balance), language (communication, expression, and understanding), and emotional functioning (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).

TBI can also cause epilepsy and increase a person’s risk for Alzheimer’s disease, Parkinson’s disease, and other brain disorders. Repeated TBI occurring over an extended period of time can result in devastating, cumulative neurological and cognitive deficits.

In his later years, Muhammad Ali described the toll that boxing had taken on his body saying, “People say I talk so slow today. That’s no surprise. I calculated I’ve taken 29,000 punches.”

Even though professional boxers can be cavalier about the risks of the sport, Gatson says they are nonetheless interested in their brain health.

“They see a lot of their friends dealing with ‘punch drunk syndrome’ or early onset dementia, and they don’t want to end up like that,” he says. “They’re interested in tools that can tell them when they need to take a break for a period of time. Or maybe it’s time to retire if their biomarkers are elevated and not coming down.”

TBI is a serious public health problem not only among athletes, but in populations throughout the United States. In fact, rates are highest among children and people 75 years of age and older. Each year, traumatic brain injuries result in a substantial number of deaths and cases of permanent disability. According to the Centers for Disease Control and Prevention, TBI contributes to about 30% of all injury deaths. Each day, 153 people die from injuries that include TBI.

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Gatson’s work has shown that the TBI tip-off enzyme CKBB can be used as a sensitive and specific biomarker to measure the immediate and long-term effects of TBI, monitor recovery rates, and pair with other biomarkers to clear a person to return to work or play.

Gatson envisions that in the future CKBB can be used as a biomarker to screen for TBI using point-of-care devices on the sports field, battlefield, or in the ambulance. “We think this biomarker can be used not only during the early phases, such as on the sidelines. The idea is that, in the future, we’ll do a finger stick and within 5 minutes we’ll know if they need to go to the ER or stay out of the game and rest,” says Gatson.

Gatson is currently working to determine how CKBB and other biomarkers can measure the effects of TBI at later time points - days, months, and years after an injury. He’s also analyzing saliva samples to see if biomarkers are present, laughing as he says that “even these tough, strong athletes don’t like to get stuck with a needle.”

Gatson emphasizes that the effects of TBI can be prolonged and this research is important in the ability to evaluate therapies. In the future, he hopes, people with trauma can go to a clinic periodically and get their biomarkers measured to screen for rapid aging or neurodegeneration.

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Ali bragged about his skill in the ring, saying “I’m not the greatest. I’m the double greatest. Not only do I knock ‘em out, I pick the round. I’m the boldest, the prettiest, the most superior, most scientific, most skillfullest fighter in the ring today.”

Dr. Joshua Gatson is a more humble man than Ali, but he’s established himself as a heavyweight researcher in the field of early detection strategies for TBI.