“Never let them know you’re hurt.” This old school mindset has become the mantra for combat sports athletes and is deeply ingrained in every fighter from the moment they decide to strap on a pair of gloves. This culture is something that makes boxing and MMA so attractive, to both participants and the audience. This culture is also to blame for many tragedies; fights that should have been stopped, fighters with permanent brain damage and fighters who lost their lives. This deep-rooted belief of hiding any signs of injury has led to gross mismanagement of mild traumatic brain injuries and concussions. I say this from personal experience as someone who has dedicated my entire life to combat sports. I was a member of the USA Boxing Team and competed at the World Championships – injured. This perspective greatly influences how I treat and manage both concussions and orthopedic injuries as a Doctor of Physical Therapy.

Concussions will always be inevitable in combat sports, there is no prevention for them. There is no headgear or mouthpiece that can protect you from a concussion. However, coaches, officials, ringside physicians, and teammates are able to play a monumental role in how these injuries are managed. This starts by changing the culture of combat sports participants, spreading awareness and education on concussions, and finally taking steps to create a change that will improve the safety of these athletes.

Often, there’s a tendency for the athlete to not disclose injuries in the leadup to a fight, due to the underlying desire to live up to expectations and the potential lack of a supportive environment for them to discuss how they’re feeling. This fear of admitting, “I’m not okay” needs to stop. Athletes need to become more open in their discussions with their coaches, divulging how they’re actually feeling, instead of saying what they think they want the coach to hear. In relation to this idea, coaches need to be more open to what their fighters need to tell them, in order to ultimately protect them from further injury. This is critical due to the fact that to diagnose a concussion we rely heavily on self-reports and visible functional deficits related to neurological impairment. At this time, as long as an athlete has one symptom of a concussion and a mechanism of injury, the athlete should be treated as if they have sustained a concussion until proven otherwise.

This is not to say that after every big shot that’s been landed, the fight or sparring needs to stop. There’s a large gray area in deciding when to stop a fight, due to things like flash knockdowns or even having a bad round in a “dog fight,” that complicates this final decision. Currently, what the research tells us is that it takes a significant force to sustain a concussion (70-120G) – so no, not every blow to the head will result in one (Broglio, Surma, & Ashton-Miller, 2011). However, during instances where the athlete is developing any symptoms, egos need to be pushed aside when fighters aren’t recovering and are not themselves. As a coach, official or corner member- if there’s a sign that your fighter is not focused in the corner, unable to respond to questions, is off-balance, seems dazed with eyes glossed over, or just not themselves, that is when a decision needs to be made. It should not be the “just 3 more minutes” mentality, sending a fighter in for one more round when they are already concussed can have the potential to lead to life and death situations.

What we know about concussions thus far, and the extent of damage that they can cause, has only scratched the surface. A protective mechanism of combat sports is that it’s a man on man sport, meaning that the competition is clearly visible in front of them, thus allowing the athlete to brace for impact if they are not able to defensively move. This is different from sports like football and hockey, where the player can be hit and blindsided, thus creating an increased acceleration/deceleration force at the head and neck, which is the main causal factor of a concussion (Schmidt, Guskiewicz, Mihalik, Siegmund, & Marshall, 2014).

When a fighter is hit and unable to brace for it, that’s when the impact becomes more dangerous and a higher incidence of KO’s is reported (Schmidt, Guskiewicz, Mihalik, Siegmund, & Marshall, 2014). Neck strength has been greatly researched in relation to concussions and is thought to help with injury prevention. However, we know that it takes 100-200ms to begin to activate muscles volitionally and takes 90ms to reach half max tension (Schmidt, Guskiewicz, Mihalik, Siegmund, & Marshall, 2014). What this means is that neck strength itself may not be enough, where instead neck “stiffness” and a fighter’s ability to brace for impact will aid in protecting them.

A further concern for combat athletes is, unlike in football and hockey, these jarring blows are often sustained multiple times to the head over the course of a fight. Currently, the literature is unclear on the impact of sub-concussive impacts and their cumulative effect. However, some studies have shown minimal cumulative effect, most notably when the injured athlete has fully recovered from concussion prior to returning to sport(Vagnozzi, et al., 2005). Physiologically, once the brain has recovered from a concussion, there is no longer an additive effect or increase in cell death from another concussion (Vagnozzi, et al., 2005). This speaks volumes for the need of these injuries to be managed correctly and for adequate, multimodal baseline tests to be performed in order to ensure these athletes are returning to the ring/cage as safely as possible.

Another important note is that concussions are not a structural injury, meaning we are unable to detect them on MRI, CT scan, or blood tests at this time (McCrory, et al., 2018). They are instead a functional injury that will typically result in impaired balance, difficulty walking, confusion, fogginess, difficulty concentrating and reduced alertness and orientation. (McCrory, et al., 2018). This also means, with “clear” imaging, there are still impairments and an injury present, we can’t rely on this as a means to return to sport or simply symptom resolution. Another reason why baseline testing is instrumental in the process of returning to sport. During a fight or sparring, if any of these signs of neurological dysfunction are observed, the fighter should not be allowed to continue, and a sports-related concussion should be suspected. This isn’t often a popular view, especially during high stake events. Adrenaline is running high, judgment is clouded, and the fighter usually has trained for months and made numerous sacrifices – no one wants a fight to get stopped. However, we must consider the consequences if the fighter is allowed to continue injured. Second impact syndrome, cerebral edema, and rise in intracranial pressure can lead to long term deficits and unfortunately, oftentimes death. Is it worth it?

Once a fighter is determined to have a concussion – along with stopping the fight, there needs to be mandated protocols in place for them to receive appropriate rehabilitation prior to getting back into the ring. There have been proposed returns to fighting protocols in the literature by Napela et al, which was also incorporated into the Association of Ringside Physicians’ concussion in combat sports consensus paper (Neidecker, et al., 2018). Napela et al’s paper proposes a stepwise progression back to the ring, that incorporates first returning to light aerobic tasks, then to non-contact sport-specific training, and finally a gradual progression to sparring with initial shorter duration rounds (Napela, Alexander, Schodrof, Bernick, & Pardini, 2017). An important point of this proposal is that there should be a 24 hr window between each stage, in which the athletes remain asymptomatic prior to progression (Napela, Alexander, Schodrof, Bernick, & Pardini, 2017). This parallels many returns to sport protocols that are well respected and utilized. In addition to this protocol, the Association of Ringside Physicians’ (ARP) is proposing that many other changes be made to protect its athletes. In summary of the ARP’s consensus paper, fighters should be given a thorough neurological exam immediately post-bout, and then again 30 minutes following in a locker room (Neidecker, et al., 2018). This isn’t currently the standard, but it is a welcome change that the sport should be striving to meet. The post-bout assessment far from the crowd, and with a lapse in time, will provide a clearer picture of the fighter’s status and if there are any developing red flags that would require immediate transport to the ER.

Additionally, a comprehensive baseline test should be performed at the start of the athlete’s career, in order to track their status throughout their fight history and ensure that they are returning to sparring without any residual deficits (Neidecker, et al., 2018). Based on animal studies, we know that our brains following a concussion are most vulnerable to additional impacts at 7-10days following a TBI, due to certain low energy levels at the cellular level in the brain at this time. During this time, it’s important to note that while most symptoms may have subsided, this does not correlate to recovery. Without a multi-modal baseline test to compare, fighters should be taken through a full return to work/play protocol as described by Nalepa, with asymptomatic 24hr windows in-between each step. This systematic practice will greatly improve the athlete’s safety on their return to the ring.

The best thing we can do to help protect the world of combat sports and its athletes is to help change the culture, to lose the “tough guy” attitude when it comes to head injuries. If you’re a coach, referee or ringside physician and you see a fighter with any symptoms, intervene. If you’re an athlete, take action to protect yourself; educate yourself and sign up for a concussion baseline test. Complete Concussion Management clinics provide athletes with multi-modal baseline tests that are loaded into an electronic system that you can access from any CCMI clinic or internet (https://completeconcussions.com). No CCMI certified clinics near you? The Impact test is provided online which is a neurocognitive baseline test that you can do independently, from your own home. (https://baselinetesting.com). Let’s change how the events are handled post-bout for the people who are putting their lives on the line for a sport they love and a chance at attaining greatness.

Author:

Destiny Chearino is a Doctor of Physical Therapy who specializes in the management and rehabilitation of combat sports athletes from orthopedic injuries and concussions. She is also a former USA National Boxing Champion; in 2014 she represented the United States at both the Continental Games in Guadalajara, Mexico capturing a Silver Medal and the World Championships in Jeju, South Korea. Understanding the lack of proper medical care for combat sports athletes, Destiny established Fighter Physio, a non-profit organization to provide rehabilitation to these athletes and serve the community she came from.

References:

Broglio, S., Surma, T., & Ashton-Miller, J. (2011). High School and Collegiate Football Athlete Concussions: A Biomechanical Review. Ann Biomed Eng [Internet], 37-46.
McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., . . . Ellenbogen, R. (2018). Consensus Statement on Concussion in Sport – the 5th international conference on concussion in sport
held in Berlin, October 2016. Br J Sports Med, 51:838-847.
Napela, B., Alexander, A., Schodrof, S., Bernick, C., & Pardini, J. (2017). Fighting to keep a sport safe: toward a structured and sport-specific return to play protocol. The Physician and Sportsmedicine Journal,
145-150.
Neidecker, J., Sethi, N., Taylor, R., Monsell, R., Muzzi, D., Spizler, B., . . . Inalsingh, C. (2018). Consensus Statement: Concussion Management in Combat Sports: Consensus Statement from the Association of
Ringside Physicians. British Journal of Sports Medicine, 53:328-333.
Schmidt, J., Guskiewicz, K., Mihalik, J., Siegmund, G., & Marshall, S. (2014). The influence of cervical muscle characteristics on head impact biomechanics in football. American Journal of Sports Medicine, 2056-66.
Vagnozzi, R., Signoretti, S., Tavazzi, B., Cimatti, M., Amorini, A., & Donzelli, S. (2005). Hypothesis of the Postconcussive Vulnerable Brain: Experimental Evidence of Its Metabolic Occurrence. Journal of
Neurosurgery, 164-71.
Marshall, C. (2019). Evidence-Based Concussion Care. Retrieved from Complete Concussion Management: https://completeconcussions.com