On July 26th the Association of Ringside Physicians (ARP), a non-profit and non-government organization of primarily fight doctors, released a consensus statement titled Concussion management in combat sports through the British Journal of Sports Medicine. The statement includes definitions and clarifications over what constitutes a concussion, an assessment of current medical suspensions and return to sport (RTS) protocols in combat sports, and a new set of guidelines that the ARP would like to see instituted to create, what the organization believes, would be a safer environment for combat athletes.
ARP Vice-President Dr. John Neidecker of the Campbell University School of Osteopathic Medicine and the Orthopaedic Specialists of North Carolina’s Department of Sports Medicine, is the lead author of the statement. Neidecker spoke to Bloody Elbow about the document and the motivation behind its creation.
“[Prior existing] guidelines, which are established and well practiced by most providers in management of concussions, really apply to non-combat sports; the more traditional things, football, rugby, soccer, things like that,” explained Neidecker. “Considering that in combat sports head contact itself is an objective and not an incidental thing, like you see in these other sports, we felt as an organization that concussion management in combat sports need to be held to a higher standard.”
To created their own guidelines, the ARP combined guidelines set out by the 5th International Conference on Concussion in Sport, which was held in Berlin, Germany in 2016, and existing protocols within the world of combat sports.
One of the statements from Berlin that is endorsed by the ARP is the definition that a concussion is, “[a subset of mild] traumatic brain injury induced by bio-mechanical forces” caused by “a direct blow to the head, face, neck or elsewhere on the body with an impulsive forces transmitted to the head.”
The typical results of a concussion, as recognized by the ARP and many other concussion management professionals, are defined as a “rapid onset of short-lived impairment of neurological function that resolves spontaneously.” The definition also stated that concussions may result in neuropathological changes to the sufferer, but that most often the acute clinical symptoms experienced reflect a “functional disturbance” rather than a “structural injury”. This means that rarely do the results of a concussion cause any kind of damage that would be noticed on neuroimaging exams, such as an MRI.
The symptoms and signs of concussion defined by the ARP in their consensus statement are:
- Somatic symptoms (headache, nausea, light/noise sensitivity, vision problems).
- Cognitive symptoms (foggy feeling, memory problems, difficult concentrating).
- Emotional symptoms (mood swings)
- Physical signs (loss of consciousness, confusion, difficulty making eye contact, slurred or slow speech, sluggish/change in fighting style).
- Balance impairment (dizziness, difficulty walking).
- Behavioural changes (such as irritability).
- Cognitive impairment (slow to react, slow to answer questions, difficulty orientating to people, location, or time).
- Sleep/wake disturbance (drowsiness, strong desire to sleep at unusual times).
Chronic traumatic encephalopathy (CTE), a condition that is created as a result of concussions (and possibly sub-concussive blows), is not mentioned in the consensus statement. CTE sufferers may experience many of the symptoms listed above long after the initial injury along with a number of other conditions including depression, attention deficit hyperactivity disorder, dementia, and suicidality. Concussions cause the brain to release the pTau proteins, which over time tangle and block nutrient flow within the organ. CTE is incredibly hard to study. A definitive diagnosis can not be made in a living brain, though there are hopes this could change very soon. However, it is widely accepted that both multiple concussions and concussions sustained in quick succession increase the pTau releases in the brain, which can lead to more severe cases of CTE.
With a view towards protecting fighters from CTE, the ARP has suggested a series of protocols to manage recoveries from concussions, with a heavy focus on preventing further damage to a concussed brain.
Currently post-concussion protocols aren’t precisely defined in the majority of athletic commissions and combat sports regulators. However, these entities do have protocols in place regarding suspensions for stoppages that occur due to blows to the head. These protocols can differ from territory to territory, but the majority of commissions suspend fighters 30 days for suffering a TKO, 60 days for a KO (without loss of consciousness (LOC)), and 90 days for a KO with LOC.
Neidecker said that one of the “big changes” the ARP are proposing with their consensus statement is that in addition to these suspensions, combat sport athletes should also be cleared by a specialist before they can return to sport (RTS).
“That’s one thing that we’ve taken from the non combat sports,” said Neidecker. “In NFL football protocol, they can’t get back to play until they are cleared by an independent neurologist.”
In the NFL, and most other team sports with concussion protocols, athletes are also removed from a game if they are deemed to have suffered a concussion and are not allowed to RTS on the day of the injury.
Neidecker said that another big change being requested by the ARP is that ringside physicians should check fighters in the locker room after a fight, in addition to the quick checks they make on fighters in the ring or cage after a fight has finished.
Neidecker explained that this change would be drastic in some territories which mandate that only a single ringside physician is required at a combat sports event, such is the case in North Carolina where Neidecker is based. Neidecker said that when he worked fights in New Jersey, there were as many as four doctors on hand, so it was easier for physicians to examine fighters backstage, while the others were present for the following fight.
“In North Carolina it’s difficult for me to go back there and take a look at things, unless I’ve made recommendations that we need to not string these fights so close together. You need to give me time to go back in the locker room and check fighters for a second time to make sure that everything is OK.”
The other guidelines recommended by the ARP are:
- 30/60/90 day suspensions for TKO and KOs should be expanded to not only bar a fighter from competition, but also from sparring.
- All fighters, including the winners of a bout, should receive an in-ring/cage examination and a backstage examination by ringside physicians to look for signs of concussion.
- Fighters should return to non-contact and conditioning training one week after TKO or KO losses and then adopt a return to fighting protocol that includes a gradual progression of intensity.
- Zero sparring or competition if an athlete is experiencing any signs and symptoms of concussion.
- If a fighter is exhibiting signs of concussion during a bout, the fight should be stopped. These signs include, but are not limited to headache, confusion, blurred/double vision, nausea/vomiting and balance/gait issues.
Neidecker agreed that stopping a boxing match or MMA fight if one combatant displays a sign of concussion would likely lead to dramatic changes in combat sports. He said, to aid this potential transition, it’s important that ringside physicians are committed to recognizing a concussion during a fight and better understanding combat sports in general.
“We definitely need ringside physicians to be well trained and well versed in head injuries and I think that comes with not just covering a fight, and just saying you’re going to be a ringside doctor, but actually being proactive and learning the craft and the art,” said Neidecker. “It’s not like any other sport ... I think it falls on the ringside physicians to be educated and be competent in being able to notice signs and symptoms of concussion in the ring and be able to make that call about when a fight should be stopped.”
Neidecker said that in order to make such a call ringside physicians need to spot signs of concussion during the action and then be able to enter the fighting area between rounds to assess athletes. “It’s difficult to do that when a round is going on, but certainly if there is something that I saw, that I was concerned about, and that fighter survived the round — you bet yourself that I’m going to go in the ring after that round has concluded to check on that fighter and look for signs and symptoms of concussions; to see if they are fine, see if they are answering questions correctly, see if they are complaining of any symptoms.”
If a fighter exhibits signs of concussion, as defined by the ARP, Neidecker agreed that a fight should be called off. But if a fighter passes a quick neurological exam, involving questions like ‘what round is it?’ and ‘where are you?’, Neidecker said he would probably allow the fight to continue.
Neidecker believes these protocols could help end fights as safely as possible, but he’s concerned that the rules in boxing, may hurt ringside doctors’ abilities to implement such an approach.
“In my opinion, I think where this is probably a bigger problem is in the sports where you do get that 10 count. In MMA, if a fighter is, for lack of a better term, ‘rocked’, and goes down, they only have a couple of seconds to collect themselves and start intelligently defending themselves before their opponents swarm on them and the fight is over. In boxing, you get that 10 seconds to get up and collect yourself and that’s the thing that, if we’re following these guidelines, it might be harder to stop a fight, at least initially. But when I’m working a boxing event and somebody gets knocked down in that round, there’s no doubt in my mind I will always be in the ring after that round to check on that fighter.”
Having more fights end on the stool in between rounds by a ringside physician would require fundamental changes to the rules of combat sports. Many commissions have it in their rules that only a referee can stop a fight (not a doctor nor a corner). This rule exists within the unified rules of mixed martial arts, which states in section 13.
The referee is the sole arbiter of a contest and is the only individual authorized to stop a contest. The referee may take advice from the ringside physician and/or the Commission with respect to the decision to stop a contest.
Even if the rules around MMA, and other combat sports, were universally amended to allow ringside physicians to call off a fight, Neidecker believes there would still be challenges to implementing the ARP’s new guidelines.
To have fights end after signs of concussion (i.e. after a fighter is ‘rocked’ in a round and then tells a doctor in the corner that he can’t remember what happened or what day it is) instead of when a fighter is unconscious or unable to defend themselves, would demand everyone involved in combat sports to adjust their expectations and redefine their understanding of how a fight is won or lost.
“A culture shift is probably one of the hardest things to do and that’s why we need exposure and education,” said Neidecker. “We’re seeing things slowly take a turn in other sports. The NFL is a prime example of this, but they’re still having their struggles and having their hard times. But things have definitely gotten better. I can say that for sure. So again it’s just more education. It’s more exposure, it’s just kind of getting the word out there. It will take some time, but I think as we learn more and more about this injury, and we are still learning a lot more about it, the culture will follow.”
The ARP is an advisory organization. It does not have the power to turn its suggested guidelines into laws for commissions to follow. Neidecker and the ARP are speaking to regulators with the hopes that these guidelines do make it into laws, but Neidecker is realistic. He said it would a “monumental task.” Ultimately the ARP’s hope is that individual ringside physicians, inside and outside of their group, adapt the guidelines into their personal practices.