The Vicious Cycle of Concussion Ignorance in Combat Sports

Dangerous misconceptions about brain injury go round and round the ring.

Posted May 30, 2020

Getting your bell rung. Taking a ‘knock on the noggin’. Taking it on the chin. Getting your lights knocked out. These are all terms used to describe contact to the head that could lead to concussion. They are used in a way that is not positive nor useful but instead minimizes the importance and danger of brain injury. These phrases underscore the lack of understanding that many have about the severity of so-called “mild traumatic brain injury”—concussion. They help feed an ethos of “Why should we care? Don’t fighters try to give each other concussions anyway?”

Knowledge transfer from one generation to the next often occurs orally from teacher to student, elder to youth, or coach to athlete. Learning directly from those who came before us, and then sharing that expertise with others, can be an effective means of passing along information. While this form of communication is often essential and beneficial, it can also exacerbate misconceptions and perpetuate anecdotal (and often incorrect) evidence.

In sport, the coach-athlete relationship involves educating and training the next generation of athletes. This relationship can be especially strong and powerful in combat sports, but it is problematic when it comes to concussion. The consensus definition of sport-related concussion is “a traumatic brain injury induced by biomechanical forces." According to this definition, concussive head injury may:

  • be caused either by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head;
  • result in the rapid onset of short-term impairment of neurological function that resolves spontaneously (but may evolve over hours);
  • result in neuropathological changes, but the acute clinical signs and symptoms are largely a functional disturbance rather than a structural injury and cannot be imaged effectively;
  • produce clinical signs and symptoms that may or may not involve loss of consciousness.

So, concussive injuries don’t require head contact, produce deficits that arise quickly and are usually brief, can’t be seen using conventional imaging, and don’t need to involve getting "knocked out." But do people active in combat sports, where concussion risk is quite high, actually know any of this? Recently we published a study called ‘Understanding concussion knowledge and behaviour among mixed martial arts, boxing, kickboxing, and Muay Thai athletes and coaches’ in the journal The Physician and Sports Medicine. We found that two-thirds of these martial artists said their coaches were their primary means of gathering knowledge about head injury and concussion. Coaches said they mostly relied on other coaches to collect and share information.

Alarmingly, as many as 86% of coaches declared they ‘never’ or only ‘sometimes’ seek information to increase their knowledge of head injury. The reality that almost all coaches were prior athletes, and that many athletes were currently involved in coaching activities, exposes a cyclical pattern of concussion knowledge in which athletes rely on poorly-informed coaches and in turn become poorly informed trainers themselves. This ignorance is trapped in a vicious cycle and never escapes the ring.

Transmitting correct information is critical when dealing with the serious and disabling injury of concussion. I have previously shared how my own post-concussive symptoms altered my capacities and led to a self-reflection of the new me. Our study demonstrates that fighters are exposed to head traumas in fight simulations, or so-called sparring sessions, typically twice a week. This information alone should be enough to focus extra attention on the risks these athletes face. Health-care professionals are rarely present during training, coaches have significant knowledge gaps and are unfamiliar with concussion assessment tools, and athletes usually do not report symptoms to avoid removal from a practice or a competition. This shows the importance of spreading reliable information on head injury knowledge, assessment, and management in combat sports. 

One member of the lab who is directly involved in the professional combat sports community has seen firsthand that combat sports athletes and coaches think loss of consciousness is a prerequisite for concussion. This is a myth: Loss of consciousness may or may not occur in a concussive incident. He recalled attending a fight event at which an athlete approached him. This fighter had been fiercely knocked unconscious and stated that he could now take part in our study since he had finally suffered his first concussion. But he had already many other concussions if one were using the appropriate definitions.

Many combat sports athletes, like the one in the anecdote and those in our study, believe a major injury is required to produce concussion. In our example, the athlete was also a coach, in which role he likely considers the occurrence of concussion among his students through the same lens and is likely passing that misconception on to the next generation of athletes, some of whom will become coaches, thus perpetuating the cycle of incorrect knowledge. Ignorance in the ring goes round and round.

Another key misconception identified in our study was on the level of brain injury a concussion is thought to represent. Very few athletes and coaches correctly understood that a concussion represents a mild traumatic injury. Interestingly, those athletes who believed a concussion represents a severe brain injury reported engaging in more sparring sessions per week and fewer indicated they had suffered a concussion in the past year relative to those who understood the actual level of severity a concussion represents. This finding introduces how education on even basic concepts may help, as the understanding of this general idea led to safer behaviour and likely a more realistic perception of concussion occurrence. Therefore, big changes appear to be achievable through small steps.

However, the vicious cycle of transferring incorrect knowledge and dangerous attitudes regarding concussion can be a challenging one to overcome. In our study coaches declared that scientific literature is neither easy to access or to interpret, and this cannot be underestimated. The use of short educational videos, computer-based learning programs, and infographics directed toward a lay audience were noted as the ideal forms of communication requested by combat sports coaches. These strategies represent the concept of knowledge translation, a process of dynamic and interactive strategies used to improve communication between researchers and knowledge users. As scientist, researcher, and martial artist, I believe it is important to acknowledge that alternative educational means must be produced to communicate effectively with different audiences. This was the main reason I started writing books more than a decade ago.

Beliefs are pervasive, and people want to adhere to ideas that make them comfortable. This can create a chain of inaccurate information that has a greater likelihood of reinforcing rather than correcting itself when information is passed from one generation to the next. By spreading accessible concussion information that promotes good practices and efforts from all parties, hopefully a vicious cycle of ignorance can become a virtuous cycle of knowledge.

This post was co-authored by Aaron Varga (honors undergraduate trainee) and Bruno Follmer (Ph.D. trainee) in the Rehabilitation Neuroscience Laboratory at the University of Victoria.

© E. Paul Zehr (2020)