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.

 

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.