Understanding Concussion Knowledge and Behaviour Among Mixed Martial Arts, Boxing, Kickboxing, and Muay Thai Athletes and Coaches (1)
Follmer, B; Varga, AA;. & Zehr, EP.
THE PHYSICIAN AND SPORTSMEDICINE 1–7 (2020)
Combat sports are unlike other contact sports, in that trauma to the brain is not only a consequence of the competition, it is one of the primary aims of the contest. As such, the risk of brain injury both in competition and training is inherently higher than other categories of sports. Sport-related concussion carries with it the risk of subsequent further concussion, which poses serious health risks, and is thought to be related to the complexity of diagnosis (2) , hesitancy in seeking medical advice (3) , knowledge gaps (4) and inappropriate behaviour (5) .
Whilst in competition, acute injury management, including the management of concussion, is typically the domain of an official medical professional, in practice this burden often falls on the sports coach.
It is hypothesised that coaches who are able to adequately identify the most prevalent and consistent indicators of a concussion (e.g. self-reported symptoms and decreases in cognition, memory, and balance), commonly assessed through practical assessment tools, could reduce the risk of subsequent and serious injuries by referring athletes to medical evaluation. It is unknown, however, the extent of concussion knowledge and understanding within the combat sports coaching community. The purpose of this study was therefore to investigate concussion knowledge and behavioural practices amongst coaches and athletes.
Participants were recruited over a 3-month period via social media and email to relevant gyms, organisations and athletic commissions. Coaches and fighters with current activity and sufficient experience in coaching mixed martial arts, muay thai or kickboxing were included. Following this process, 70 athletes and 35 coaches were included in the study. Most athletes had over 10 career fights, and most coaches had coached at professional, international or national levels.
A combination of the Rosenbaum Concussion Knowledge and Attitudes Survey – Student Version (RoCKAS-ST) and a personal questionnaire were used as the primary outcomes measures. The
Combat sports are unlike other contact sports, in that trauma to the brain is not only a consequence of the competition, it is one of the primary aims of the contest. As such, the risk of brain injury both in competition and training is inherently higher than other categories of sports. Sport-related concussion carries with it the risk of subsequent further concussion, which poses serious health risks, and is thought to be related to the complexity of diagnosis (2) , hesitancy in seeking medical advice (3) , knowledge gaps4 and inappropriate behaviour (5) .
RoCKAS-ST is comprised of two sections, the concussion knowledge index (CKI), which assesses the individual’s knowledge around concussion theory and accurate identification of symptoms on a scale of 0 to 25, and the concussion attitude index (CAI), which assesses the safety of an individual’s attitudes towards concussion on a scale from 15 to 75. Separate personal questionnaires were used with athletes and coaches, and covered demographic and personal characteristics, training/coaching experience, history of concussion, and knowledge translation. Comparisons were made between athletes based on gender, skill level and weight class.
Some of the important participant demographics were the number of sparring sessions per week (average of 2, range 0-10) and the use of headgear (always -31.4%, often – 20%, sometimes – 17.1%, almost never – 22.9% and never – 8.6%). Interestingly, of the 40% of coaches who believed that the use of headgear contributes to protection against concussion, only 50% always required its use for sparring. In terms of the intensity of head punches thrown during regular sparring sessions, 5.7% of coaches described the intensity as extremely light, 21.4% light, 64.3% moderate and 8.6% heavy, while amongst the athletes, none perceived the intensity as extremely light, 37.1% light, 54.3% moderate and 8.6% heavy.
The self-perceived rating of knowledge of concussion was 5.89/10 in men and 6.93/10 in women. Other than this difference between genders, there were no other
differences in outcome measures between different groups.
Athletes were questioned regarding what level of brain injury (mild, moderate or severe) a concussion represented. Athletes correctly answering “mild” were those performing fewer sparring sessions per week. Most of the athletes believing a concussion represents a moderate (97.6%), or severe (94.1%) traumatic brain injury reported not suffering a concussion in the previous years, whereas this number dropped to 63.6% in the group correctly understanding concussion to be a mild traumatic brain injury.
Over half of the coaches reported having an athlete suffering a concussion in the previous year, with 31.4% having witnessed a loss of consciousness in training. The episodes of suspected concussion (72.9%) were more than the number of diagnosed concussions (50%).
68.5% of coaches and athletes reported a licensed medical professional either never or hardly ever being present for training. 41% of athletes having suffered a concussion reported returning to training within 1 week of diagnosis, with this number being higher in professional athletes.
The majority of athletes (70%) utilised their coaches as the main source of concussion information, followed by mass media (64.3%) and team mates (54.3%). Despite this, 31.4% of coaches reported not actively seeking education regarding concussion. 80% of coaches considered short educational videos to be the optimal form for consuming concussion-related information.
As with the study we reviewed in the June issue regarding the safety of sportive chokes, this survey-based convenience study does have its inherent limitations in terms of the sample of participants. Given the avenues of recruitment, it is difficult to gauge whether the level of education and behavioural characteristics of those surveyed would be reflective of the wider combat sports community. However, given the spread over several different disciplines (Muay Thai, boxing, kickboxing, MMA) and levels of competition, as well as the fact that there was minimal difference between different groups of athletes in terms of questionnaire response, the data may well provide us with a valid representation of current trends.
Given this, there are several rather concerning issues raised. The first is that the many of the athletes surveyed relied on their skills training coaches for concussion information and guidance. Sports skills coaches, particularly in combat sports, often take on roles that are arguably outside their scope of practice, including strength and conditioning programming and injury (including concussion) advice. Given that the majority of the coaches surveyed in this study were not actively seeking concussion education, it is likely that the information and advice that athletes are receiving from their coaches is inaccurate and potentially harmful. 68.6% of coaches reported not being familiar with any form of concussion assessment tool.
It also appears evident that knowledge and self-perception of knowledge does not translate into behaviour change, as female athletes, whose concussion knowledge was
presumed to be superior, engaged in similar behaviours as their male counterparts. One of the most disturbing of these behaviours was premature return to activity, a behaviour which has been reported in previous studies3 ,6. This is thought to be due to a belief that concussion is not a serious issue7 , but specifically in female athletes may be related to a fear of poor perception from coaches and teammates8 . In addition, a belief from coaches that headgear was partially protective of concussion did not result in adherence to its use. The authors speculated that this may be due to research suggesting that whilst protective of other head, face and brain damage, headgear has not been shown to be protective of sporting concussion9 , and it has also been theorised that head guards may actually induce more aggressive behaviour and actually increase concussion risk 1 0. Due to the nature of the questionnaire, however, these details were not confirmed.
However, it was demonstrated that those with a greater understanding around the severity of a concussion engaged in fewer sparring sessions, potentially as a deliberate attempt to reduce concussion risk.
Misunderstanding regarding the symptoms of concussion was another issue made evident through this study. This is a common concern amongst medical professionals in relation to combat sports athletes, as an inability to acknowledge signs and symptoms of concussion will inevitably lead to inappropriate management and a failure to seek medical intervention.
Combat Sports Performance Research Review – July 2020
“Bruno Follmer is a big proponent of knowledge translation, and there is arguably no more important aspect right now in combat sports science where a gap between research findings and common practice needs to be more effectively bridged”
The authors acknowledge some issues with the CKI questionnaire, in particular the true/false question “after 10 days, symptoms of a concussion are usually completely gone”, which, whilst technically true, may not be contextually appropriate for the population it is intended to be utilised with.
Whilst this study helps paint a picture of trends in terms of knowledge, understanding and behaviours around concussion, the reasons behind these behaviours could perhaps be further investigated. Doing so may help identify future interventions aimed at improving culture and processes.
This study reinforces the findings of previous studies, that concussion understanding and management amongst combat sport athletes is quite poor4 . The risks and repercussions of concussion are many. Premature return to activity following concussion increases the risk of the second impact syndrome (SIS), which may have potentially hazardous consequences. Furthermore, incomplete recovery from
concussion before a return to sport may increase the risk of musculoskeletal injury.
Repeated concussion often results in a lower threshold for concussions to occur, and once this occurs can have a huge negative impact on a fighter’s career. Whilst most concussions will recover in a relatively short period of time, there are instances where this is not the case, and symptoms may be experienced for years, greatly impacting on an individual’s quality of life. This may lead to long-term mental health issues and has in some instances resulted in suicide1 1. Therefore, there needs to be a change in the culture of concussion education and management. The lead author of this study, Bruno Follmer, is a big proponent of knowledge translation, and there is arguably no more important aspect right now in combat sports science where a gap between research findings and common practice needs to be more effectively bridged. How this is done, however, poses an enormous challenge.
1. Follmer, B., Varga, A. A. & Zehr, E. P. Understanding concussion knowledge and behavior among mixed martial arts, boxing, kickboxing, and Muay Thai athletes and coaches. Phys. Sportsmed. 1–7 (2020).
2. Harmon, K. G. et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin. J. Sport Med. 2 3, 1–18 (2013).
3. Heath, C. J. & Callahan, J. L. Self-reported concussion symptoms and training routines in mixed martial arts athletes. Res. Sports Med. 21, 195–203 (2013).
4. Lystad, R. P. & Strotmeyer, S. J. Concussion
knowledge, attitudes and reporting intention among adult competitive Muay Thai kickboxing athletes: a cross-sectional study. Inj. Epidemiol. 5 , 25 (2018).
- Saffary, R., Chin, L. S. & Cantu, R. C. Sports medicine: Concussions in sports. Am. J. Lifestyle Med. 6 , 133–140 (2012).
- Bennett, L. L., Arias, J. J., Ford, P. J., Bernick, C. & Banks, S. J. Concussion reporting and perceived knowledge of professional fighters. Phys. Sportsmed. 47, 295–300 (2019).
- McDonald, T., Burghart, M. A. & Nazir, N. Underreporting of concussions and concussion-like symptoms in female high school athletes. J. Trauma Nurs. 2 3, 241–246 (2016).
- Delaney, J. S., Caron, J. G., Correa, J. A. & Bloom, G. A. Why professional football players chose not to reveal their concussion symptoms during a practice or game. Clin. J. Sport Med. 28, 1–12 (2018).
- McIntosh, A. S. & Patton, D. A. The impact performance of headguards for combat sports. Br J Sports Med 49, 1113–1117 (2015).
- Hagel, B. & Meeuwisse, W. Risk compensation: a “side effect” of sport injury prevention? (LWW, 2004).
- Fralick, M. et al. Association of concussion with the risk of suicide: a systematic review and meta-analysis. JAMA Neurol. 76, 144–151 (2019).