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Traumatic Brain Injury
Concussion in Combat Sports Is an Iceberg Under the Ring
Ignorance sent the Titanic to its doom; knowledge can save combat athletes.
Posted April 11, 2022 Reviewed by Ekua Hagan
Key points
- Scientific evidence is clear that exposure to hits to the head can lead to brain injury.
- Combat sports practitioners are chronically exposed to intentional head impacts in training and competition.
- Prevention of unnecessary impact through improved knowledge and behavior change can alter the fate of these athletes.
“But this ship can’t sink!”—Bruce Ismay, managing director of the White Star Line commenting on the Titanic
“She’s made of iron, sir! I assure you, she can. And she will. It is a mathematical certainty.”—Thomas Andrews, shipbuilder and architect of the Titanic
—Dialogue from the feature film Titanic (1997)
It’s helpful to learn from the past. April 15, 2022 marks the 110th anniversary of the sinking of the “unsinkable” Titanic. This event has become a classic example of how arrogance and disdain can lead to devastating and long-lasting consequences. Shipbuilders and regulators learned and created protocols and innovations for safer construction and navigation.
Over a decade later, in 1928, Harrison Martland wrote about combat sports causing brain damage. His paper “Punch Drunk” was the first clear statement on the existence and dangers of concussions in combat sports. Unlike lessons from icebergs in the North Atlantic, however, in the 10 decades that followed Martland’s warning very little has changed in combat sports. Still many disdain research and safety by saying, essentially, that the goal of fighting is precisely to cause that kind of injury, so who cares? Well, we all should.
As with the surface of the sea obscuring what lies beneath, what you see on the surface of the ring in combat sports such as boxing and mixed martial arts is one athlete trying to incapacitate the other, often by strikes directly to the head. This essence definitely increases the risk of what lies beneath—brain injury.
But this doesn’t mean we shouldn’t care. On the contrary, we must worry even more. What is visible on the surface of the ring represents only the tip of an iceberg of dangerous aspects that need to be cautiously revealed and explored.
Bruno Follmer and I wrote an opinion article in the British Journal of Sports Medicine that addresses the special intention, exposure, and reach that differentiate combat sports from all other modalities when it comes to head injuries.
Combat sports include the intention to hit the head
Intention: In most sports, the intention is to score points, like in soccer, football, hockey, and basketball. Head impacts are, therefore, concerning and uncommon events, even subject to sanctioning. Experts say athletes must be removed at the first suspicion of concussion—for example, with the observation of motor incoordination, vacant look, and loss of consciousness. The intention is way different in fighting. Head impacts are the most common event in striking modalities, and often a fight continues even if one (or both) athletes present visual signs of concussion. “If in doubt, sit them out” is the main motto for concussion prevention in sports, but not easily applicable in fighting.
Combat sports athletes are exposed to too many concussive events during training
Exposure: Professional fighters compete only a few times per year with oversight by ringside physicians and medical care. Despite the clear risk in competition, the exposure to head impacts in training is the most worrisome. One of our previous studies showed that fighters are exposed to numerous hits to the head in two simulated fights per week in training. That’s more than 100 simulated fights per year. Given that medical presence is rare in the gym, athletes and coaches are the ones managing potential concussions, even though there is a vicious cycle of concussion ignorance among them. The real danger to these athletes’ brains occurs in the darkness and depths of the gym and not in the bright of the spotlights and pay-per-view events.
Combat sports have universal appeal and reach
Reach: Combat sports are popular all over the world, regardless of social class or financial status. Different from other sports, fighting does not require favorable weather, sophisticated equipment and attire, or a specific terrain for practice. Weight classes account for the inclusion of distinct body types for both sexes. Also, it only takes two to tango and to fight.
Historically, fighting has been a sporting event since at least 648 BC in ancient Greece with Pankration. Nowadays, the popularity and wealth of combat sports companies and athletes draw many young people into these unsafe waters. Aside from the competitive level, a plethora of inexperienced practitioners are driven by the discipline and health benefits of combat modalities, but susceptible to head injury as a by-product. The contribution of combat sports to the overall concussion burden in sports is likely underestimated given the deep and global reach of these modalities.
When ignorance is the problem, education is always the answer
Education is the most powerful tool we have to dodge the iceberg. Unfortunately, recent interest and scientific discoveries have not reached the general public nor combat sports athletes and coaches. The lack of knowledge and perpetuation of bad practices is clear. In the ’60s, Muhammad Ali’s coach reported that “Ali believed that suffering was an important part of his preparation for a fight, that a man could build up tolerance for blows to the head and body in much the same way that you one might build up tolerance for spicy food.”
MMA superstar Wanderley Silva always trained with the firm belief that he would get more resistant if repetitively hit in the head during training. Recently, he admitted to suffering from chronic concussion symptoms. When navigating these risky waters, education in concussion can lead to a change of direction that can ultimately change the destination of many combat sports athletes.
Whether by omission or disdain, failing to acknowledge the depths of head trauma in combat sports will permit foundering on the solid and dangerous iceberg of ignorance that clearly exists. While all involved in combat sports must seek better and more reliable sources of information about head injuries, scientists must learn to communicate better with their target audience. The next consensus statement on concussion in sport appears in a timely manner to endorse the relevance of combat sports modalities and better guide those who already or intend to navigate these waters. So far, we have barely touched the surface, especially around prevention. Yet, regardless of our perspectives, danger lurks in the depths and the only way to defeat the danger is by changing our practices.
Just as the danger to ships from icebergs lies just under the surface of the water, the danger to combat sports athletes lies under the skin just beneath the surface of the skull. The Titanic unknowingly sailed towards its doom. Unlike that ill-fated voyage, we have lots of evidence for the risks and dangers of head trauma and concussion in combat sports and clear ways to implement changes in practice. Unlike the Titanic, this ship doesn’t have to sink.
Note: This post was a collaboration with Bruno Follmer, a Ph.D. candidate in the Rehabilitation Neuroscience Laboratory at the University of Victoria and Instructor at the School of Kinesiology at Capilano University, Vancouver, Canada.
(c) E. Paul Zehr (2022)
