1 Concussion in Boxing and MMANitin K Sethi, MD, MBBS, DNB (Int Med), FAAN Assistant Professor of Neurology New York-Presbyterian Hospital Weill Cornell Medical Center New York, NY Director and Chief Coordinator Brain Care Foundation Diplomate of National Boards (DNB) Internal Medicine (India) Diplomate American Board of Psychiatry and Neurology (ABPN) Diplomate American Board of Clinical Neurophysiology (ABCN) with added competency in Central Clinical Neurophysiology, Epilepsy Monitoring, Intraoperative Monitoring Diplomate American Board of Psychiatry and Neurology (ABPN) with added competency in Epilepsy Diplomate American Board of Psychiatry and Neurology (ABPN) with added competency in Sleep Medicine Diplomate American College of Sports Medicine (ACSM)/Association of Ringside Physicians-Certified Ringside Physician

2 Fundamental questions:What is a concussion? How common are concussions in contact sports such as boxing and MMA? How to identify concussions in the ring/octagon? Can concussions be identified with confidence ringside? How to manage concussions in the ring and in the locker room? Acute traumatic brain injuries in boxing and their immediate management.

3 Things to consider: Contact sports like boxing, MMA, football-concussions common Incidence varies among-professional Vs. amateur athletes Age groups vulnerability-pediatric (children/adolescent) > adult Gender vulnerability-female boxer/MMA fighter >male boxer/ MMA fighter Main goal in boxing (lesser degree in MMA) is to win by causing a concussion. Potential risk and degree (mild Vs. severe) of neurologic injury both acute and chronic is high. Deaths have occurred in the ring/octagon

4 Concussion: No single definition!AANS-clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma. AAN: alteration of mental status due to a biomechanical forces affecting the brain. AAN definition does not require a loss of consciousness. 2012 Zurich Consensus Statement on Concussion in Sport: complex pathophysiological process affecting the brain. Definition allowed for the presence of neuropathological damage. However, concussive symptoms largely thought to reflect a functional disturbance, typically resolving spontaneously with no imaging abnormality. Proposed that concussion and mild TBI be viewed as distinct entities Practical definition: clinical syndrome that depends on a clinical history of head injury or sudden force, typical symptoms, and findings on physical examination.

5 Concussion is confusing us all!Concussion has no clear definition and no pathological meaning. Historically used to describe patients briefly disabled following a head injury, with the assumption that this was a transient disorder of brain function without long-term sequelae. Symptoms of concussion are highly variable in duration, may persist for many years with no reliable early predictors of outcome. Term concussion leads to misconceptions and biases in the diagnostic process, uninterpretable science, poor clinical guidelines and confused policy. Term concussion should be avoided. Attempt to classify the severity of TBI and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms. Sharp DJ, Jenkins PO. Concussion is confusing us all. Pract Neurol 2015;15:

6 Two potential classification systems for traumatic brain injury and concussion.David J Sharp, and Peter O Jenkins Pract Neurol 2015;15: ©2015 by BMJ Publishing Group Ltd

7 Concussion is confusing us all!separating concussion as a distinct pathophysiological entity from TBI very problematic. no clear pathological definition to distinguish concussion from other types of TBI, and the injuries leading to concussion are biomechanically similar to other types of TBI. unclear how a clinician might decide between mild TBI and concussion, as the symptoms and signs of concussion also follow other types of TBI

8 Mayo Traumatic Brain Injury (TBI) Classification SystemClassify as Moderate–Severe (Definite) TBI if one or more of the following criteria apply: Death due to this TBI Loss of consciousness of 30 min or more Post-traumatic anterograde amnesia of 24 h or more Worst Glasgow Coma Scale full score in first 24 h <13 (unless invalidated upon review eg, attributable to intoxication, sedation, systemic shock) One or more of the following present: Intracerebral haematoma Subdural haematoma Epidural haematoma Cerebral contusion Haemorrhagic contusion Penetrating TBI (dura penetrated) Subarachnoid haemorrhage Brainstem injury If none of Criteria A apply, classify as Mild (Probable) TBI if one or more of the following criteria apply: Loss of consciousness momentarily to less than 30 min Post-traumatic anterograde amnesia momentarily to less than 24 h Depressed, basilar or linear skull fracture (dura intact) If none of Criteria A or B apply, classify as Symptomatic (Possible) TBI if one or more of the following symptoms are present: Blurred vision Confusion (mental state changes) Daze Dizziness Focal neurological symptoms Headache Nausea

9 Boxing: let us talk statisticsIn amateur boxing, incidence of concussion or other head injury to be between 6.5% and 51.6% of all injuries. For professional boxers, concussion and head injury rates higher, estimated to be between 16% and 70% of all injuries. Concussion rates for both amateur and professional boxing substantially higher than in other sports, ranging between 14 and 45 per 100 AEs.

10 Boxing: let us talk statisticsincidence of serious acute head injury in amateur boxing and noncompetitive boxing believed to be lower than in professional ranks in a study of instructional boxing in the United States Marine Corps, only one serious head injury occurred per 60,000 participants, only 0.3% of all boxing-related injuries during the study period. amateur boxing participants suffered a severe concussion or multiple knockouts in 0.58% of competitions. in professional boxers, studies examining the sport in New York State demonstrated knockout rates of 3% per participant in the 1950s, and about three head injuries per 10 boxers in the 1980s. a study of professional boxing from Nevada documented an overall injury rate of of 17.1 per 100 boxer matches. male professional boxers more likely to be injured than female professional boxers. boxers who lose by knockout have twice the risk of injury as those who do not.

11 Acute Neurological Injuries in Boxing:Traumatic amnesia (retrograde and anterograde)-CONCUSSION Groggy state- CONCUSSION/ ACUTE POST CONCUSSION SYNDROME Subdural hematoma (SDH): major cause of boxing related mortality-TRAUMATIC BRAIN INJURY Epidural hematoma (EDH)-TRAUMATIC BRAIN INJURY Subarachnoid hemorrhage (SAH)-TRAUMATIC BRAIN INJURY Intracranial hemorrhage-TRAUMATIC BRAIN INJURY Diffuse brain contusions without associated hemorrhages-TRAUMATIC BRAIN INJURY Diffuse axonal injuries (DAI)-TRAUMATIC BRAIN INJURY Dissection-vertebral artery/ carotid artery-TRAUMATIC CEREBROVASCULAR INJURY

12 Concussion-before and after (the face is a mirror of the brain)

13 Concussions in Boxing/MMA (can we grade it?)Grade 1 (mild): "out on the feet”-unable to defend himself, looks dazed, may stagger around the ring or rests on the rope. Grade 2 (mild): boxer is knocked down and cannot rise before the count of ten, but does not experience loss of consciousness. Grade 3 (moderate): boxer is rendered unconscious but recovers quickly. Grade 4 (severe): similar to grade 3, except the period of unconsciousness is longer.

14 Common clinical manifestations of concussion (the groggy state):Headache-unlikely to be reported by fighter, but if he does-STOP THE FIGHT! Dizziness Imbalance-staggers to his corner Irritability-lashes out at referee, corner, inspector, physician Fatigue Poor memory-difficult to assess ringside between rounds Dysarthria-difficult to assess ringside between rounds Confused-does not remember the round, walks to the wrong corner after the bell Dazed look (glassy eyes)

15 Anatomy of a concussion

16 Anatomy of a concussion

17 Biomechanics of boxing concussionsConcussive properties of a boxer's punch related to the manner in which the punch is delivered, how the mechanical forces are transferred and absorbed through the intracranial cavity. Blows thrown from the shoulder, such as the roundhouse or hook, tend to deliver more force than the straight forward jab. The force transmitted by a punch is directly proportional to the mass of the glove and the velocity of the swing, and is inversely proportional to the total mass opposing the punch. The essential feature of a concussive force is that the force is sufficient enough to accelerate the skull. Rotational (angular) acceleration, linear (translational) acceleration, and impact deceleration can all play a role in the development of acute cerebral injury. Angular acceleration occurs when a punch causes a rotational movement of the skull that can potentially stretch and tear cerebral blood vessels. Linear acceleration occurs from blows directly to the face in an anterior to posterior direction, which may result in gliding contusions. Rotational acceleration more commonly induces a concussion and often causes diffuse brain injury. Force produced by a blow is usually some variable combination of linear and rotational acceleration. Once a boxer is knocked down and strikes the cranium on the floor mat, a rapid deceleration (impact deceleration) occurs that can result in contrecoup contusions.

18 Concussion is not unique to boxing

19 A hierarchical approach to the management of mild traumatic brain injury.David J Sharp, and Peter O Jenkins Pract Neurol 2015;15: ©2015 by BMJ Publishing Group Ltd

20 Management of concussionNational Institute of Health and Care Excellence (NICE) Guidelines for determining the need for an acute CT scan of the head in adults following a traumatic head injury CT scan of head within 1 hour if any of the following are present: -Glasgow Coma Scale (GCS) score <13 on initial assessment -GCS<15 2 hours after injury -Suspected open or depressed skull fracture -Any sign of basal skull fracture -Post-traumatic seizure -Focal neurological deficit ->1 episode of vomiting since the head injury CT scan of head within 8 hours if: -Current warfarin treatment -Loss of consciousness or amnesia and any of the following: Age >65 years A history of bleeding or clotting disorder Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from height of more than 1 m or five stairs) More than 30 min retrograde amnesia of events immediately before the head injury

21 Management of post-concussion symptoms

22 Acute Neurological Injury in Boxers

23 Management of Acute Neurological Injury in Boxers

24 Management of Acute Neurological Injury in Boxers

25 Ban Boxing-yes or no? Position Statements on BoxingAmerican Medical Association (2007): Recommends that until boxing is banned, head blows should be prohibited American Academy of Pediatrics (1997): Opposes boxing as a sport for any child, adolescent, or young adult Australian Medical Association (2007): Opposes all forms of boxing; recommends the prohibition of all forms of boxing for people younger than 18 y British Medical Association (2007): Opposes amateur and professional boxing; calls for complete ban on boxing; recommends banning boxing for those younger than 16 y Canadian Medical Association (2002): Recommends that all boxing be banned in Canada World Medical Association (2005): Recommends that boxing be banned

26 Ban Boxing-yes or no? Australian Medical Association Position (Boxing Reaffirmed 2007) All forms of boxing are a public demonstration of interpersonal violence which is unique among sporting activities. Victory is obtained by inflicting on the opponent such a measure of physical injury that the opponent is unable to continue, or which at least can be seen to be significantly greater than is received in return. This particularly applies to professional boxing. 1. The AMA opposes all forms of boxing. 2. The AMA recommends to the International Olympic Committee and the Australian Commonwealth Games Association that boxing be banned from both the Olympic and Commonwealth Games. 3. The AMA recommends the prohibition of all forms of boxing for people under the age of 18. 4. The AMA recommends that media coverage of boxing should be subject to control codes similar to those which apply to television screening of violence. 5. Until such time as boxing is banned, the AMA supports the following steps designed to minimize harm to amateur and professional boxers:

27 Is there double standard when it comes to concussion?do we treat boxers/MMA athletes different from other athletes (NFL players/ soccer players)? as things stand now-concussions are identified in boxing/MMA but not managed (the show must go on!) as things stand now-concussions are identified in NFL and managed! (the player is pulled out, submitted to concussion screening on sideline/locker room and benched)

28 Is there double standard when it comes to concussion?as things stand now we are only trying to prevent/manage acute TBI in boxing. we are learning that multiple concussions can lead to CTE. so we are trying to prevent CTE in NFL players but not in boxers!

29 Boxing-Brutal or Brilliant?-The Sweet Science"Float like a butterfly, sting like a bee.“ "When you are as great as I am, it is hard to be humble.“ Muhammad Ali

30 Thank you