Should transgender athletes be allowed to participate in combat sports? Will this be a fair bout and more importantly a safe bout (from the perspective of health and safety of both the combatants)? Attached is a PowerPoint presentation where in I discuss this polarizing topic.
Tag: boxing
COVID-19 and combat sports: when and how to begin bouts again?
COVID-19 and combat sports: when and how to begin bouts again?
Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)
DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.
Professional boxing and mixed martial arts (MMA) are popular sports with a worldwide fanbase. COVID-19 (coronavirus disease 2019) is the infectious respiratory disease caused by SARS-COV 2 virus (Severe Acute Respiratory Syndrome coronavirus 2). On March 11th,2020 The World Health Organization (WHO) declared COVID-19 a pandemic considering the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread. 1 In order to control the spread of COVID-19, heath care authorities in different countries recommended isolation of sick persons, quarantine for those who may been exposed to the virus and social distancing. 2 Social distancing also referred to as physical distancing meant keeping space between people outside of their homes. A distance of at least 6 feet (2 meters) was recommended and people were asked not to gather in large groups, avoid crowded places and mass gatherings. Widespread cancelation or postponement of sporting events including boxing and MMA bouts followed. The most common sited cause for cancelation was fear of contagion. The encyclopedia describes contagion as the communication of disease from one person to another by close contact. By canceling events, State Commissions, promoters and combat sport’s governing bodies made the tough but responsible decision to protect all the concerned parties namely the athletes, their camps, Commission officials, production crews and the fans at the venue.
The global death toll from COVID-19 has been devastating. COVID-19 has infected more than 2 million people and killed at least 132,276 worldwide as of April 15th 2020 according to the coronavirus resource center at Johns Hopkins University. 3 The pandemic affected each and every one of us fundamentally changing the way we live our lives. The pandemic has peaked in many European countries and the United States. While deaths continue to mount, new cases and admissions are declining. Governments are now turning to the complex question of how and when to open different states and countries to business and normal life. For combat sports to resume this summer we should explore the possibility of initially holding events “behind closed doors”. Only the athletes, cornermen, referee, judges, Commission officials, ringside physicians and TV production crew would be present at the venue. The rationale for holding an event behind closed doors will be to reduce the risk of COVID-19 transmission from person to person by restricting the number of people at the venue to under 50. In the past month many SARS-COV 2 diagnostic test kits have become available. Some of these can be administered at the point-of-care with a turnaround time of 24 hours. It is proposed that all (not just combatants) present at the closed door event undergo a coronavirus screening questionnaire and be tested for SARS-COV 2 in the week leading up to the event. Social distancing should be practiced at the time of the weigh-ins and also the event itself. Corner men, referee, judges, Commission officials, ringside physicians and TV production crew should wear a surgical face mask (N 95 respirator is not warranted), gloves and eye-protection during the course of the event.
We should acknowledge that even if an event is held behind closed doors and all those present (not just the athletes) are tested for the coronavirus, the risk of transmission from person to person remains. Controlling the spread of the COVID-19 pandemic is far bigger than any boxing or MMA event. It is a matter of social responsibility and an obligation to act for the benefit of the society at large. By adopting some of the above practices a cautious start to combat sports events can be contemplated.
COVID-19 and combat sports-to fight or not to fight?
COVID-19 and combat sports: to fight or not to fight?
Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)
DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.
Professional boxing and mixed martial arts (MMA) are popular sports with a worldwide fanbase. COVID-19 (coronavirus disease 2019) is the infectious respiratory disease caused by SARS-COV 2 virus (Severe Acute Respiratory Syndrome coronavirus 2). On March 11th,2020 The World Health Organization (WHO) declared COVID-19 a pandemic considering the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread. In order to control the spread of COVID-19, heath care authorities in different countries recommended isolation of sick persons, quarantine for those who may been exposed to the virus and social distancing. Social distancing also referred to as physical distancing meant keeping space between people outside of their homes. A distance of at least 6 feet (2 meters) was recommended and people were asked not to gather in large groups, avoid crowded places and mass gatherings. Widespread cancelation or postponement of sporting events including boxing and MMA bouts followed. The most common sited cause for cancelation was fear of contagion. The encyclopedia describes contagion as the communication of disease from one person to another by close contact. By canceling events, State Commissions, promoters and combat sport’s governing bodies made the tough but responsible decision to protect all the concerned parties namely the athletes, their camps, Commission officials, production crews and the fans at the venue.
Some promoters have explored the possibility of holding a combat sports event “behind closed doors”. Only the athletes, cornermen, referee, judges, Commission officials, ringside physicians and TV production crew would be present at the venue. The rationale for holding an event behind closed doors is to reduce the risk of COVID-19 transmission from person to person at the venue. It was further proposed that all athletes be tested for SARS-COV2 before entering the ring or cage. The term “behind closed doors” is used primarily in association with football (soccer) to describe matches played where spectators are not allowed in the stadium to watch. Soccer matches are played behind closed doors to punish a team when its fans display rowdy behavior and clash with the rival team supporters and is included in the FIFA Disciplinary Code. 3
Amid the COVID-19 pandemic should combat sports events be held behind closed doors? Crowd less bouts are rarely heard of in combat sports. Passionate frequently blood hungry fans vociferously and voraciously support their prizefighter and are as much a part of the sport as the athletes themselves. Combat sports athletes fight not just for fame and money, they fight for their fans in the venue. Holding a crowd less event takes the very essence and vibe out of a combat sports event. Just like water is the elixir of life, so is the combat sports fan to the sport itself. Even if an event is held behind closed doors and all those present (not just the athletes) are tested for the coronavirus, the risk of transmission from person to person remains. Controlling the spread of the COVID-19 pandemic is far bigger than any boxing or MMA event. It is a matter of social responsibility and an obligation to act for the benefit of the society at large.
The stunned brain: neuroanatomical correlates of an acute concussion in boxing
The stunned brain: neuroanatomical correlates of an acute concussion in boxing
Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)
Abstract
A concussion can be defined as a transient alteration of mental status due to biomechanical forces affecting the brain. Concussions are common in contact sports like boxing and mixed martial arts (MMA). In boxing frequently the goal is to win by causing a knockout (KO)/concussion though a fight may also be won by a body shot if the boxer is unable to continue. This is then ruled a technical knockout (TKO). In the case report that follows, the clinical semiology of an acute concussion in boxing is described and a speculative hypothesis about the neuroanatomical correlate of the syndrome is postulated.
Case Report
A-32-year old right handed professional male boxer with a record of 20 wins, no losses with 10 of the wins coming by way of knockout suffered a brutal KO during a high profile televised bout. The boxer went down with the head striking and then bouncing off the ring canvas. Immediately on impact with the ring canvas the boxer exhibited decerebrate posturing followed by a 20 second convulsion characterized by stiffening of the arms and low amplitude clonic jerks of the legs. The referee immediately signaled an end to the fight and motioned the ringside physician to enter the ring to tend to the downed fighter. Examination inside the ring revealed a conscious boxer (eyes open) with unresponsiveness (no response to commands). This conscious unresponsiveness state lasted for about one minute. Pupils were midsize, equal in size with sluggish response to light. The emergency medical service (EMS) personnel stationed ringside were summoned into the ring by the ringside physician. While maintaining spinal fixation, the boxer was placed in a hard cervical collar and lifted on to and strapped on a hard backboard. As this was been accomplished, the boxer suddenly became responsive and started punching the air with his gloved hands as if he was back in the midst of the bout. He was combative and attempting to get up from the board. He was restrained by the medical staff. After about 1 minute, he calmed down and became fully alert and oriented. He realized that the fight had been stopped because of a KO and requested the medical staff to allow him to get up. At the post-fight medical evaluation he was determined to have suffered an acute concussion and administered a 90 day medical suspension. A neurology clearance was also requested prior to return to competitive boxing.
Discussion
The 5th international conference on concussion in sport held in Berlin, October 2016 defined a sport related concussion (SRC) as a traumatic brain injury induced by biomechanical forces resulting in the rapid onset of short-lived impairment of neurological function that resolves spontaneously 1. However, in some cases, signs and symptoms may evolve over a number of minutes to hours. While SRC may result in neuropathological changes, the acute clinical signs and symptoms largely reflect a functional brain disturbance rather than a structural injury with no abnormality seen on standard structural neuroimaging studies such as CT or MRI.
The centripetal theory of cerebral concussion postulates that in a concussion there is a centripetal progression of strains from the outer surfaces to the core (midbrain and basal diencephalon) of the brain 2, 3, 4. The anatomical localization of memory is in the temporal lobes or orbitotemporal regions. As per the centripetal theory, less degree of force does not penetrate deep into the cortex and so while cognitive and memory dysfunction may result, consciousness is retained. Forces strong enough to penetrate through to the mesencephalic brainstem result in loss of consciousness. It is important to remember that the above theory and biomechanical concepts are largely based on primate research and not on humans. The observation that brainstem signs can occur in the absence of significant “cortical” symptomatology and that cortical signs can occur in the absence of significant “brainstem” symptomatology means that the centripetal theory explains some but not all of the varied clinical semiology of concussion. It is generally accepted that traumatic decerebration, short duration traumatic coma (loss of consciousness) and impact seizure are brainstem release phenomena in which cortical inhibition of normally suppressed brainstem activity is lost due to diffuse cerebral injury. It may also be that the above phenomena are primarily due to failure of activity in the mesencephalic reticular formation and with loss of brainstem reflex response without widespread cortical involvement. The amnestic symptoms noted during a concussion have been postulated to be due to a transient interruption or disturbance in the ascending cortical projections at the level of the mesencephalon. It is hence intriguing to think of a “brainstem concussion” distinct from a “cortical concussion” each with different clinical semiology and symptom complex 4.
The above described clinical semiology of an acute concussion in boxing has not been described thus far in the medical literature. While this “stunned brain syndrome” is unnerving to witness as a physician neurologist because of its dramatic presentation and rapid evolution; the syndrome is self-limited with the boxer returning to baseline neurological function usually in the ring itself. It likely has the bulk of its anatomical focus in the brainstem with some cortical and subcortical contribution.
Understanding the neuroanatomical correlates of an acute SRC as in boxing has important implications for our conceptual understanding of concussion and acute management of these injuries in the ring.
References
- McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 2017; 51:838-847.
- Ommaya A. Head injury mechanisms and the concept of preventative management: a review and critical synthesis. J Neurotrauma1995; 12:527–46.
- Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. Brain1974; 97:633–54.
- McCrory P. The nature of concussion: a speculative hypothesis. British Journal of Sports Medicine 2001; 35:146-147.
Ensuring and Maintaining Brain Health of the Combat Sports Athlete
Ensuring and maintaining brain health of the combat sport athlete
Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)
DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.
Combat sports such as professional boxing and mixed martial arts (MMA) are popular sports with high risk for both acute and chronic traumatic brain injuries (TBI). Unfortunately, combatants have died in the ring or soon after the completion of a bout usually due to an acute catastrophic neurological event such as an acute subdural hematoma (SDH); which has been documented to be the most common cause of boxing related mortality. Acute TBI is just the tip of the iceberg when it comes to neurological injuries caused by combat sports. Hidden under the surface and away from the eyes of the public and media are the equally devastating chronic neurological sequelae of boxing and MMA including but not limited to chronic posttraumatic headache, chronic posttraumatic dizziness, posttraumatic cognitive impairment, posttraumatic Parkinsonism, posttraumatic dementia, dementia pugilistica, punch drunk syndrome, chronic traumatic encephalopathy (CTE) and neuropsychological sequelae such as mood, behavioral changes and depression.
At present there are no validated imaging or bio fluid (blood, cerebrospinal fluid) biomarkers for concussion and many of the above chronic neurological sequelae of boxing and MMA. In the absence of biomarkers; prognostication of the brain health of a combat sports athlete is inherently difficult. Most combatants undergo neuroimaging at the time of applying for initial licensure to compete in combat sports. This entails a magnetic resonance (MRI) scan of the brain without contrast usually carried out on a 1.5 or 3 Tesla strength magnet. In some countries and Commissions in the United States, a computed tomography (CT) scan of the head is acceptable in lieu of the MRI brain. While neuroimaging prior to licensure helps detect incidental clinically silent structural lesions with a high risk of bleeding such as aneurysm, arteriovenous malformation, large cavernoma, vein of Galen malformation and brain tumors, it does not yield any useful information about the function of the brain. Hence combining structural imaging with a functional study of the brain such as a formal neurocognitive evaluation should be considered at the time of initial licensure. Neurocognitive testing is a way to measure brain function non-invasively. It uses paper-and-pencil tests or computerized tests to assess important aspects of cognition such as attention, memory (immediate recall, short-term, long-term, auditory, visual), language, reaction time, perception and so on after factoring in the IQ and formal education of the examinee. A formal neurocognitive evaluation carried out by a qualified neuropsychologist is extremely helpful to formally assess the function of the brain as well as the mind and to grade/score it. The above test combo carried out at the time of the initial licensure serves as the baseline against which future test results are compared.
The average professional career of a combat sports athlete spans 10 years. During their active career most combatants fight on an average 2-6 times per year. It is recommended that a combat sports athlete undergo repeat MRI brain and neurocognitive evaluation after every 3 years. If the MRI shows evidence of prior TBI such as an area of encephalomalacia or gliosis, diffuse axonal injury, micro hemorrhages and the neurocognitive scores show a demonstrable decline, the combatant should be flagged. These combatants may need further tests such as PET scan of the brain, an electroencephalogram (EEG) and referral to a neurologist. On a case by case some may be allowed to proceed with their career under close observation while others may be counseled to hang up their gloves in order to prevent further and at times irreversible brain damage.
The brain is like a muscle and needs to be exercised, nourished and nurtured. The more it is exercised the stronger it becomes. Use it or lose it has scientific validity. Combat sports athletes should be counseled about brain health and how to build their cognitive reserve by doing exercises such as crossword puzzles, playing chess, reading, writing, listening to music or learning a new language or musical instrument. Supplements such as magnesium oxide and vitamin B12 are generally acknowledged to be brain healthy. A brain healthy Mediterranean diet which entails cooking food in extra virgin olive oil, less of dairy, less of red meat, more fish, more nuts should be promoted.
It is further recommended that the various sports commissions in the United States and abroad and combat sport’s governing bodies coordinate to assist with the setting up of an online central neuroimaging and neurocognitive database so that neuroimaging and neurocognitive data can be shared in the different countries where the combatant may compete.
The above interventions shall help to maintain the brain health of the combat sports athlete.
Reference
1. Sethi NK. Neuroimaging in contact sports: Determining brain fitness before and after a bout. SA J. Sports Med. 2017. vol.29 n.1 http://dx.doi.org/10.17159/2078-516x/2017/v29i0a2390
The conflict between combat sports and ethical medicine: can they co-exist?
The conflict between combat sports and ethical medicine: can they co- exist?
N K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America
Corresponding author: N K Sethi (sethinitinmd@hotmail.com
Disclosure: The author serves as the Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed above are those of the author and do not reflect necessarily the views of the New York State Athletic Commission.
Address correspondence and reprint requests to:
Nitin K. Sethi, MD
Associate Professor of Neurology
Comprehensive Epilepsy Center
New York-Presbyterian Hospital
Weill Cornell Medical Center
525 East, 68th Street
New York, NY 10065
Email: sethinitinmd@hotmail.com
Tel: + 212-746-2346
Fax: + 212-746-8845
Even after so many years, there are times when my love and passion for combat sports collides head on with my love and passion for medicine and protecting athletes health.
One would assume that these 2 passions would not cause any conflict in me and for a while it never did. On many weekends, I would be at Mendez Boxing hitting the bag while wearing my favorite T-shirt proudly emblazoned “Neurologist-because awesome is not a job description”. My friends at Mendez know me and call me simply “doc” and some of my most memorable moments have been spent in their company discussing combat sports.
I once gave a lecture to a body of my peers at my hospital. The topic I chose was “Neurological injuries in boxing”. I spoke passionately about the topic. To my dismay, many of my colleagues disagreed with my involvement in combat sports and got up and left midway. I felt hurt but my passion and love for both combat sports and Neurology remained unchanged. But recent events have forced me to come to terms with my involvement as a ringside physician in combat sports.
One principle has always helped me when I find myself struggling and that is that I am there ringside or cage side for only one thing. To stop a fight once I feel the threshold has been reached beyond which I cannot guarantee a fighter’s health and safety.
The fighters are professionals skilled and trained to do their job. They always command my greatest respect. I too am a professional skilled and trained to do my job. My threshold of stopping a fight may differ from a fighter or a fan’s threshold of stopping a fight. It may also differ from a referee’s threshold of stopping a fight. As a physician one cannot defend combat sports by saying that boxing or MMA is good for the brain or the body. No amount of boxing or MMA is good for the brain-not one round, not even one punch to the head or to the body. Ringside or cage side I need to remain objective, completely free of any bias and make a call to stop a fight based solely on the medical facts in front of me not the fighter’s fight record and certainly not based on how big the fight is and how much money is at stake. The minute I do that, I fail to remain an objective doctor and I rather be a spectator occupying a seat at the venue rather than wasting a seat ringside or cage side. My judgement is going to be biased and I am now primed to fail in my only duty which is to protect the athlete’s health.
Do I have all the answers? No. But sometimes under tremendous pressure I must make a call. It does not matter whether the setting is the ER, the ICU or the bright lights of a combat sports arena. Why would I treat a patient that I am seeing in the ER after an assault on the street differently from an athlete who has sustained similar injuries inside a ring or a cage? If I am concerned about an assault victim, I am not going to tell him all is well and just discharge home from the ER. No, I shall admit him and do the necessary medical evaluation and management. Why should my approach be different cage side or ringside just because it is a big fight? If it is, I have no right to be present there for I am failing my patient (the athlete) who has trusted me with his/her health on entering the cage or the ring.
The ringside/ cage side setting is far more challenging to practice medicine than the controlled environment of the ER or the hospital. I must make a call and I must make it fast. I do not have the luxury of doing labs or a CT scan. It is all clinical with only the athlete in front of me. And yes, contrary to some people’s view it does take 15 to 18 years of intense medical training to make this call-which athlete has only suffered a concussion and can be discharged home versus one who may be about to develop a far more serious traumatic brain injury. You only have to encounter an unconscious person on the street to realize how tough it is and how helpless you feel without a doctor on hand. And I need to make the right call for there may never be a second chance for me to re approach my patient and change my decision.
It is unfortunate and dangerous when an experienced referee, inspector, judge or ringside physician is afraid to make a call because he/she is worried how the decision shall be viewed by the public and other parties. When they are worried whether their decision is going to cost them the opportunity of working the next “big” fight. Would you (if you were a patient) trust this doctor with your most precious possession of good health?
I am not saying that medical decision making in combat sports should not be critically appraised. Every medical stoppage should be looked at, studied and learnt from. Was it right or was it wrong? But there is a way to do this and it is not online. Telling a doctor that he is a “fucking scum”, screaming for his blood so that he fears for his own health and safety as he heads out of the arena is certainly not the way. Thrashing his reputation online is also not the way. Most ringside physicians practice ringside medicine a mere 1% of their total time practicing medicine. We work in hospitals and we have regular jobs. We do not do ringside medicine for the money. We are paid anywhere between $200 to $400 for the night, a night where we tirelessly work upto 12 hours under exceptionally difficult circumstances. That is below minimum wage. We do what we do because we care.
It is understandable why even my own peers in Neurology and Medicine do not support the work of ringside physicians and call for a ban on all combat sports. Combat sports and ethical medicine cannot co-exist without conflict. The gap is too large to bridge.
Today, I again struggle to bridge my love for medicine and combat sports.
Making boxing safer: when to stop a fight on medical grounds
Making boxing safer: when to stop a fight on medical grounds
N K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America
Corresponding author: N K Sethi (sethinitinmd@hotmail.com
Disclosure: The author serves as the Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed above are those of the author and do not reflect necessarily the views of the New York State Athletic Commission.
Address correspondence and reprint requests to:
Nitin K. Sethi, MD
Associate Professor of Neurology
Comprehensive Epilepsy Center
New York-Presbyterian Hospital
Weill Cornell Medical Center
525 East, 68th Street
New York, NY 10065
Recently the boxing world was heart broken by the untimely demise of boxer Patrick Day. By the accounts of all who knew him, Patrick was an intelligent well-spoken young man who was loved by all. He died at the tender age of 27 after suffering devastating traumatic brain injury (TBI) during the course of a professional boxing bout. Patrick was no rookie stepping into the ring for the first time. He was an accomplished boxer with a record of 17 wins and 4 losses in professional boxing. His amateur record was 75-5.
Following Patrick’s death, the boxing community has been looking inwards and searching for answers on what went wrong that eventful night and what can be done to prevent such tragedies in the future. Unfortunately, there are no easy answers. In a sport where every punch thrown at the head is thrown with the intention of winning by causing a knock-out (KO) (aka a concussion); the risk of TBI lurks all the time. Many still do not understand that deaths when they do occur in the ring are not the result of a single blow (punch) to the head; rather it is the culmination of multiple head shots which the fighter sustains during the course of the bout. Importantly the initial signs of a concussion/TBI are subtle and wholly subjective. The fighter may experience a headache, subjective feeling of dizziness or imbalance, vision problems and difficulty in focusing. There are no objective signs which can help the ringside physician, the referee, the inspectors and the corner men identify the concussion/TBI with confidence. By the time objective signs such as gross motor instability (GMI) (obvious balance problems, lack of coordination or inequality in pupil size) appear, the TBI is usually well evolved and precious little can be done ringside to save the boxer’s life except to transport him to the hospital in an emergent fashion for life saving brain surgery. Usually a decompressive hemicraniectomy is carried out for evacuation of the blood clot and to reduce the intracranial pressure. Even though surgery in some of these cases may save the boxer’s life, he is usually left behind with significant and permanent neurological deficits such as motor weakness, speech and cognitive deficits and problems with coordination and gait. Hence the goal should remain to stop a fight early rather than late. A good stoppage done by the referee or the ringside physician on medical grounds is one which is done for the right indication such as concern for TBI and at the right time (neither too early, certainly never too late!).
Standardizing medical stoppages in the ring is no easy task but certainly something which we all should be paying closer attention to. One approach which can be adopted is to establish NO-GO criteria in boxing. If any of the NO-GO criteria are encountered during the course of the bout, the bout should be stopped on medical grounds to protect the health and safety of the boxer. Ringside physicians, referee, the Commission officials, the corner men and most importantly the two boxers should be aware of these NO-GO criteria.
In order to identify and prevent acute TBI in boxing, the following good practice guidelines and NO-GO criteria are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:
The fight should be stopped if the boxer voices any of these complaints or displays any of these signs at any time during the course of the fight:
1. If the boxer voices complaint of headache.
2. If the boxer is displaying overt signs of a concussion and gross motor instability (GMI). These signs include but are not limited to confusion and disorientation, impaired balance and coordination.
3. If the boxer suffers any duration of loss of consciousness after a KO. This boxer should not be allowed to continue even if he gets up at the count of 8. It is good practice for the referee to waive off the count in these instances, signaling an end to the contest so that the fighter can immediately be attended to by the ringside physician medical team.
4. If the boxer suffers an impact seizure or displays fencing responses at the time of a KO. This boxer should not be allowed to continue even if he gets up at the count of 8. It is good practice for the referee to waive off the count in these instances, signaling an end to the contest so that the fighter can immediately be attended to by the ringside physician medical team.
5. The boxer suffers loss of visual acuity during the course of a fight. This is usually on account of trauma to the eye. Loss of visual acuity results in an impaired fighter who cannot defend himself/herself effectively. Allowing the fight to continue risks the health and safety of the boxer.
6. The boxer suffers loss or restriction of visual field during the course of a fight. This may be on account of trauma to the eye, neural mechanisms which control eye-movements or due to swelling around the eye (peri-orbital swelling). Restriction of visual fields results in an impaired fighter who cannot defend himself/herself effectively. Allowing the fight to continue risks the health and safety of the boxer
7. If the boxer becomes a physically compromised fighter during the course of a fight. This usually occurs on account of injury to the hands/shoulders or the lower extremity (knee or ankle injury) leading to inability to defend oneself from the opponent.
8. If the boxer starts to vomit during the course of the bout, the fight should be stopped (caveat is that boxers will sometime vomit after a hard body or liver shot).
Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight
Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight
Nitin K Sethi, MD, MBBS, FAAN
Chief Medical Officer, New York State Athletic Commission
Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY 10065 (U.S.A.)
Disclaimer: the views expressed in this article are mine and do not necessarily reflect the views of the New York State Athletic Commission (NYSAC).
In the ring and cage during a fight:
1. If concern for concussion or traumatic brain injury arises during the course of the bout, the ringside physician shall assess the combatant preferably between the rounds. The evaluation will be carried out by the ringside physician during the 1-minute break between rounds or after the 1-minute break but before commencement of the next round by requesting the referee to call a time out. The ringside physician shall assess the combatant with the use of Maddocks questions. Maddocks questions include but are not restricted to:
a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?
2. The ringside physician shall conduct a focused neurological evaluation of the combatant in the ring/cage. This evaluation shall include:
–asking the combatant if he/she has any subjective complaints such as headache, dizziness, visual disturbances, nausea, feeling off-balance.
–giving the combatant a two-step command (touch your right ear with your left glove).
–assessment of pupil size symmetry and reactivity (integrity of cranial nerves II and III)
–assessment of extraocular movements (integrity of midbrain and pons by assessment of cranial nerves III, IV and VI)
–assessment of cerebellar function and infratentorial compartment integrity by checking gait and stance (stand still with feet together and/or tandem gait).
The ringside physician should be aware of the NO-GO criteria. If any one of the NO-GO criteria is present, consult with Chief Medical Officer (CMO)/Assistant Chief Medical Officer (ACMO) and consider advising the referee to stop the fight on medical grounds.
The NO GO criteria are the following:
1. If the combatant exhibits any period of LOC or unresponsiveness after a KO.
2. if the combatant exhibits confusion (any disorientation or inability to respond appropriately to questions) at time of assessment by ringside physician.
3. If the combatant exhibits amnesia (retrograde / anterograde) when assessed by the ringside physician. The ringside physician shall assess for retrograde and anterograde amnesia in the ring/cage using Maddocks questions including but not limited to:
a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?
4. If the combatant voices to the ringside physician or his corner any new and/or persistent subjective symptoms such as headache, nausea, dizziness.
5. If the combatant vomits during the course of the fight (this criterion should not be used in isolation to stop a fight on medical grounds).
6. If the combatant has an abnormal neurological examination (ataxia, impaired balance, pupil size asymmetry and/or reactivity) when assessed by the ringside physician.
7. If the combatant has a concussive seizure also at times referred to as an impact seizure (seizure occurring at the time the fighter’s head makes impact with the ring/cage canvas).
In the post-fight examination area/locker room after the fight is over
The ringside physician shall assess for the presence or absence of concussion/ traumatic brain injury with the aid of a multimodal concussion screening and assessment battery including but not limited to:
a) Glasgow Coma Scale Score (best motor response, best verbal response and eye-opening). CGS score less than 13 is mandatory transfer to the emergency department (ED) of the designated Level I Trauma Center via on-site ambulance for urgent CT scan head to rule out acute traumatic brain injury.
b) Detailed neurological examination including higher mental function testing, cranial nerve II to XII testing, pronator drift testing, assessment of motor function, finger to nose testing, tandem gait assessment and Rhomberg’s test.
c) Standardized Assessment of Concussion (SAC) test-check orientation, immediate memory, concentration, delayed recall (see attached SAC form).
d) Balance Error Scoring System (BESS) test-double leg stance, single leg stance and tandem leg stance (see attached BESS testing procedure).
Management of a concussed combatant is on a case by case basis with majority of combatants discharged from the venue with a medical suspension. Duration of the suspension may vary from 30 to 90 days with mandatory 90-day suspension and follow up with a neurologist if the concussion occurred by a KO. All combatants discharged home from the venue are instructed to remain in close observation of a family member/coaching staff for the next 24 hours with instructions to report to the nearest emergency department (ED) if any neurological symptom (headache, dizziness, blurred vision, vomiting, impaired balance) or sensorium (lethargy, unresponsiveness) is reported. All discharged combatants are educated about post-concussion symptoms with instructions to seek medical care if these are reported. A combatant may be referred to the ED of the nearest Level I trauma center for an urgent CT scan of the head and further evaluation if deemed appropriate by the ringside physician. Transport in these cases shall take place via on site ambulance.
References
1. Neidecker J, Sethi NK, Taylor R, Monsell R, Muzzi D, Spizler B, Lovelace L, Ayoub E, Weinstein R, Estwanik J, Reyes P, Cantu RC, Jordan B, Goodman M, Stiller JW, Gelber J, Boltuch R, Coletta D, Gagliardi A, Gelfman S, Golden P, Rizzo N, Wallace P, Fields A, Inalsingh C. Concussion management in combat sports: consensus statement from the Association of Ringside Physicians.Br J Sports Med. 2019;53(6):328-333. doi: 10.1136/bjsports-2017-098799.
2. Erlanger DM. Exposure to sub-concussive head injury in boxing and other sports. Brain Inj. 2015;29(2):171-4. doi: 10.3109/02699052.2014.965211.
3. Jayarao M, Chin LS, Cantu RC. Boxing-related head injuries. Phys Sportsmed. 2010;38(3):18-26. doi: 10.3810/psm.2010.10.1804.
4. Galetta KM, Barrett J, Allen M, Madda F, Delicata D, Tennant AT, Branas CC, Maguire MG, Messner LV, Devick S, Galetta SL, Balcer LJ. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology. 2011 Apr 26;76(17):1456-62. doi: 10.1212/WNL.0b013e31821184c9.
5. Potter MR, Snyder AJ, Smith GA. Boxing injuries presenting to U.S. emergency departments, 1990-2008.Am J Prev Med. 2011 Apr;40(4):462-7. doi: 10.1016/j.amepre.2010.12.018.
6. Sawauchi S, Murakami S, Tani S, Ogawa T, Suzuki T, Abe T. Acute subdural hematoma caused by professional boxing. No Shinkei Geka. 1996 Oct;24(10):905-11.
NO-GO criteria in boxing
NO-GO criteria in boxing
Nitin K Sethi, MD, MBBS, FAAN
Associate Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10065
Chief Medical Officer, New York State Athletic Commission
New York State, Department of State
The fight should be stopped if the boxer voices any of these complaints or displays any of these signs at any time during the course of the fight:
- If the boxer voices complaint of headache.
- If the boxer is displaying overt signs of a concussion and gross motor instability (GMI). These signs include but are not limited to confusion and disorientation, impaired balance and coordination.
- If the boxer suffers any loss of consciousness after a KO. This boxer should not be allowed to continue even if he gets up at the count of 8.
- If the boxer suffers an impact seizure or displays fencing responses at the time of a KO. This boxer should not be allowed to continue even if he gets up at the count of 8.
- The boxer suffers loss of visual acuity during the course of a fight. This is usually on account of trauma to the eye.
- The boxer suffers loss or restriction of visual field during the course of a fight. This may be on account of trauma to the eye, neural mechanisms which control eye-movements or due to swelling around the eye (peri-orbital swelling).
- If the boxer becomes a physically compromised fighter during the course of a fight. This usually occurs on account of injury to the hands/shoulders or the lower extremity (knee or ankle injury) leading to inability to defend oneself from the opponent.
- If the boxer starts to vomit during the course of the bout, the fight should be stopped (caveat is that boxers will sometime vomit after a hard body or liver shot)
Disclaimer: the views expressed above are those of the author and do not necessarily reflect the views of the New York State Athletic Commission.
Can boxing be made safer? Yes but the culture needs to change
N K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America
Disclosure and Disclaimer: N.K Sethi serves as Chief Medical Officer for the New York State Athletic Commission (NYSAC). The views expressed are his only and do not reflect the views of the NYSAC.
KEY WORDS: boxing; traumatic brain injury; concussion; death
Recently the boxing world has been mourning the loss of a number of boxers in the ring or in the immediate aftermath of a bout. As physicians we take an oath to always protect the health of our patients and while ringside medicine is practiced in a different arena than within the confines of a hospital or ER, our duties and obligations to protect the health and safety of the fighters should never waiver for when they enter that ring or cage, they entrust us with their most precious possession of health. Few realize the pressures doctors work under at ringside. Once I had to make the difficult decision to stop a bout on medical grounds with only 30 seconds left on the clock in the last round. I stopped the fight only to be berated by the fighter’s corner like I have never been before. The F word was used repeatedly for what I had done and I was told in rather colorful language of what they thought of my action. I remained calm and stepped away after ensuring the fighter was safe.
As I see it, when I “hung up my gloves” at the end of a long night, I had the satisfaction of knowing that I had done the job which I am entrusted with to the best of my capability. That job is to protect my fighter first and foremost. As a fan, yes I may see it differently and want the fight to go down to the end but we are not there in the capacity of a fan of the sport, we are there as doctors with one and only one job to protect the fighter.
Yes 30 seconds in boxing do matter. In boxing one punch can be the difference between life and death. One punch can kill! So while we as ringside physicians endure the wrath of the corners, the media and sometimes the fighter himself let us not let this discourage or intimidate us to comprise on fighter safety. In the end there is nothing like going to bed with a feeling of a job well done.
We have to continuously strive to provide the best medical care and attention to the fighters. Analyzing what we do and improving our current medical policies and protocols should be an ongoing task. The more time I spend ringside, the more I realize that boxing is a unique sport for a physician to be involved in and that the odds are stacked against us ringside. In the office or hospital/ ER setting, a patient comes to us mostly voluntary seeking help and care. On questioning, he/she gives us a detailed history. The family is at times there to supplement the history. Contrast that to the ringside where on direct questioning, frequently the patient (boxer) and his family (corner) falsely deny that anything is wrong and are often upset and angry that we even dared to ask the question. After a fight is over, it is not infrequent to encounter a boxer and his corner who refuse to go to the ER for medical evaluation. “I am fine doc, I am not going” is the deviant answer. These boxers and their corner staff fail to appreciate that symptoms in some people with head injuries don’t show up immediately! (walking, talking and dying syndrome). That is the reason why physicians recommended to observe people after a head injury for 24 hours.
When I last checked, none of us physicians have X-ray vision so how are we expected to make a medical call from a distance without the benefit of an honest history or a quick examination? Many do not realize that once a brain bleed has occurred and the pupils are unreactive (fixed) and dilated, there is precious little we physicians can do ringside to “save” that athlete. Even if that athlete reaches the hospital alive in a timely fashion as a result of our collective efforts, the resulting decompressive surgery is carried out as a last ditch palliative life-saving procedure. That athlete shall never be the same again and will have significant residual neurological deficits. Our goal should be to prevent such a devastating injury from ever occurring in the first place and not just to manage it after it has unfortunately occurred.
A few years ago, I wrote a short letter titled “Boxing can be made safer” in response to an editorial in a leading neurology journal calling for a ban on boxing and MMA. I argued passionately that boxing and MMA can be made safer with improved medical policies designed to protect the health and safety of the combat sport athlete. I still stand by my stated position that boxing can be made safer but the change has to come from inside. In the National Football League (NFL), the culture has already changed from a previously held view of “suck it up and shake it off” to one of “if you feel something, sit it out“. Athletes are now encouraged to report their symptoms of concussion/traumatic brain injury (even if minor and subjective) to the athletic trainers and doctors on the sidelines.
The word “No mas” (Spanish for “No more”) gained boxing notoriety when Sugar Ray Leonard fought Roberto Duran II on November 25, 1980. At the end of the eighth round Durán turned away from Leonard towards the referee and quit by apparently saying, “No más“. Duran’s stature was never the same again after he uttered those 2 words. Over the years, the boxing culture has evolved to one of never saying “No mas”. The fighter’s mentality is never to quit no matter what the circumstances. Doing so brings disgrace to the fighter, his family and his corner. This mentality and culture needs to change, Boxers and corner staff should be educated and encouraged to actively recognize and report to the ringside physician any subjective symptoms of concussion and TBI such as headache, subjective feeling of dizziness or light headedness, blurring of vision, double vision, confusion and a feeling of fogginess. “When in doubt, sit it out” is not equivalent to “No mas”. “For he that fights and walks away, may live to fight another day” historically attributed to Demosthenes, a Greek orator should be the new mantra of boxing. There is no shame in this; just smartness.
The boxing culture needs to change and this change shall come over time with education. As physicians it is our duty to educate the boxing community and I hope physicians who practice ringside medicine shall join me in this effort.
Together we can make a difference and making boxing safer.
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