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One size does not fit all!

ELITE MMA Referee School

Gotta' go with fighter safety. A loss can be avenged. Brain damage cannot be reversed.



One size does not fit all!

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Diagnosis and Management of Concussion in Boxing and Mixed Martial Arts Combatants

On Tuesday, March 29, 2011, participants were invited to a live webinar called "Diagnosis and Management of Concussion in Boxing and Mixed Martial Arts Combatants," featuring Peter Q. Warinner, M.D., neurologist and founder of the Sports Neurology and Concussion Clinic at the Brigham and Women's/Mass General Health Care Center. Sponsored by a generous grant by the Brigham and Women's Hospital, the seminar was held at the Bornstein Amphitheater in Boston, MA.

The following are some of the excerpts from that webinar which most fighters, their trainers and MMA professionals will be interested! (Please note there are times when I’ve had to cut some of the copy down due to length or interpret.)

According to Dr. Warinner, “One size does not fit all,” so guidelines must be developed to fit “most” fighters. Recommendations for diagnosis and management of a concussion:





  • * Clinical Considerations for someone who’s suffered from a concussion – it’s a case-by-case evaluation, and the potential for symptoms can range from immediate to seeing symptoms as far as a week out.
  • * Loss of consciousness is not necessary in diagnosing a concussion!
  • * Second-impact syndrome can be cause by rapid deceleration to the head, so when the head comes to an abrupt halt but the brain keeps moving and smashing against the head, this can cause a concussion. So your head need not have been hit, in fact, to get a concussion.



  • * Fighters and their trainers need to be aware of 2nd-impact syndrome, post-concussion syndrome, and the long-term consequences of multiple concussions.
  • * While we can’t continue to look the other way when a fighter gets hit in the head, we also don’t want to force him/her to stay out of the game for longer than they need to. That said, each case must be diagnosed individually, because the importance of the fighter’s health is of primary importance.

Suggestions for improved safety include:


The fighter should obtain an MRI or CAT scan within 6 mo’s of the event before getting approved to fight again. Some fighters will need to be told they cannot fight. The problem is, if a state tells them this – but they don’t share it if they fight in another country or on an Indian Reservation, or a state that is not regulated…then what’s to stop them from not saying anything, and fighting anyway, to the detriment of their health and even life?

Suggestions for improving fights:

  • * Mandatory head gear, thicker gloves, shorter rounds, better matchmaking, lower threshold for referees to stop the fight.
  • * National Standards for pro and ammy licensing or for criteria for licensing.
  • * Mandatory and improved education for fighters, promoters, referees, judges and ringside physicians.

There must be some genetic vulnerability in a person that creates a potential for more brain injury to a fighter who gets a small blow to the head, as compared to a fighter who gets pummeled, but has no apparent affects. As a result, we need to conduct more research so we can assist and prevent future issues.



Mike Constintino @ AMA: How to handle a paying customer who takes 15 min’s to recover and says they’re ok to continue?

RESPONSE: Protect the person and make them see a physician and get cleared to continue.

5 time World Boxing champion, Virgil Hill: What’s happening to you when your bell gets rung?

RESPONSE: The suspicion is that some sort of concussing has occurred and you should be treated as such.

Sean Deaton: At UFC in Newark, NJ fighters suspended due to head injuries and MRI’s. Absolutely necessary? What effect does the radiation from these tests cause fighters in their resting/recovery state, if this becomes a requirement after ever fight?

RESPONSE: If some med official deemed they need scanning, combined with a neuro-type of exam, is imperative. The radiation from a CAT scan is relatively low so it’s not an issue…if it’s your 30th CAT scan – that can be an issue.

Dr. Weinstock out of NY state w/ the NYSAC: Question is about potentially devastating head drama, especially a blow resulting in forceful neck extension. Should we be screening for silent or a-symptomatic cervical spinal stenosis, with its potential (?) risk for central cord syndrome, resulting in acute quadriplegia?

RESPONSE: Part of what ringside physicians do and sports physicians its understanding is that blows to the head are also about the neck and spinal cord and yes it could result in spinal cord injury, soft tissue, etc., so it’s important to also screen for these injuries.

From a former boxer, Darrell Stanuski (sp?): Does head gear really do anything to protect your head from injury?

RESPONSE: I don’t know! He thinks it probably does to some extent – but maybe it goes the other way, where when people have head gear on, they feel more protected and like a battering ram. It’s not a given.,

Lorenzo Gracie (trainer): is a dehydrated fighter at greater risk and why?

RESPONSE: I would say definitely, yes. In medicine we have this concept of two medical conditions happening at one time. When your do many things can happen such as a sodium imbalance in a fighter’s circulation and exposure to tissues which ca lead to seizures, etc. add that to a concussion or head blows.

From Randy Couture: As a competitive fighter and trainer I’m concerned with the long-term effects of concussion impacts that are blamed, particularly those incurred chronically during to training and sparring. Can you offer some practical advice, or offer some alternatives to the repetitive impact syndrome, that the current model of preparation manifests. Thank you for your answer and for keeping me and all fighters safe.

RESPONSE: This is a hard one to answer! The answer is that there probably is some consequence for having repeated blows to the head, which will manifest itself differently depending on the fighter, so one person alone cannot be helped. There is potential risk, but it can only be measured on an individual basis, and we won’t know the true effects until time has passed.

UFC Trainer: What initial assessment tool or protocol tool do you use during a pro-MMA or boxing match, if any. Like a pre-fight assessment exam before entering the cage or better yet, in between rounds.

RESPONSE: Pretty much it’s left up to the ref’s and ringside physician who are better qualified at that time to assess the situation and/or injury.

Judge: when a comp suffers a cut is there a diff in the brain’s ability to maintain top level cognitive function if its venus vs arterial cut.

RESPONSE: Depends if the cut is due to inside or outside of the head. If it’s from skin being ruptured on the skin from small arteries and shows bright red blood, then it’s generally not very harmful. It it’s a strong blow to the head and could be a skull fracture, which is extraordinarily rare in fighting but it can happen…it could be rapidly fatal. It’s usually seen in other forms of trauma.

Question #2: Are there any neurological behavioral indicators that could assist judges in identification and appraising of damage aside from the obvious ones such as momentary lapses in consciousness i.e. equilibrium balance and coordination, so a judge can determine which fighter inflicted the more telling blow, and the more subtle indications of damage so we can render even more accurate, precise scores.

RESPONSE: Well – that’s the biggest challenge we all face. That’s real time…while the fight is going on, and that’s why we have the officials watching what’s going on so any of them can step in and stop the fight. No real pearls of wisdom other than what you’ve said and proper education of all those involved, and proper matchmaking, ambulance close by, the ER, etc.

Dr. Lenny Weis: In boxing many standing 8 counts are a result of being dazed by a punch. Is this a concussion? Standing 8 count passé?

RESPONSE: Probably is and perhaps the fight should be stopped or he’d suffer a worse post fight concussion recovery or 2nd impact syndrome.

Kyle: How can boxing justify nature of the sport with increased awareness of concussion dangers. Boxers are given an opportunity to compose themselves after a concussion.

RESPONSE: Be aware of the consequences and submit to informed consent.

Audience: Are there medications that can be prescribed to help con injury

RESPONSE: Yes and no. none FDA approved, but are many symptoms that can be treated through medicines and it’s important to think about what shouldn’t be used. For example: Citicoline has been what I would call shown to be effective in treating traumatic brain injury. Not positive this is the right stuff, so check with your doctor or the board, before using any!!!

Avoid narcotics and opiate type meds, as they can cause cognitive impairment and other problems. For headache’s other things can be used. Not going to list them here…check w/your doctor!


Audience: What’s the difference between traumatic brain injury (TBI) concussion injury?

RESPONSE: Concussion is a form of TBI and TBI is a broader concept. You have concussion and various other types of concussions within TBI; bleeding inside the epidural in the skull but outside the tissues, subdural bleeding, etc., you’ve got contusions, which is like bruising of the brain, so you’ve got different forms of TBI.


Audience:  Why is brain imaging required for pro fighters before fighting and what’s the difference between an MRI and a CT scan?

RESPONSE: You can’t p/u a concussion on current modalities of brain imaging. So we’re basically looking for other problems for example if a person has a brain tumor or other vulnerability that would cause us to caution an individual from fighter.


For example, recently someone had a very large cystic structure in their brain which if they were left alone they’d probably be fine, but it was causing a shift in the brain already…now add a blow to the head – and the person could really suffer from a TBI, so for that person, this imaging and discovery was important to not clear them.


CT scan is an image that can look at bone structure, fractures brain bleeding, etc. An MRI gives you better resolution in brain tissue.


To all fighters...

The medical community is here to help you who cares about your safety and your future well-being. In fact, if anyone is willing and able to help, please contact Dr. Warinner at the hospital here:



Many thanks to Dr. Sherry Wulkan for her assistance in chairing this presentation and creating this project.


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