EDUCATING THE REFEREE
Transcription of Dr. Bennett Derby’s Lecture on Concussion: “The purpose of this course is to provide the physiological principles on which procedure rests. The decisions are yours. The information permitting you to approach those decisions is what I want to go after right now. This course is for both referees and ringside physicians. It is deliberately constructed in this way because both kinds of people together form a healthcare team.” Minimizing the Damage “Although the name of the game in other sports is various kinds of contact that may be complicated by concussion and head injury, in boxing it is the total name of the game. The whole point for both boxers is for one participant to produce concussion in the other. This means that you must be prepared to assess the presence of concussion, the length of concussion, how many of them are happening and, most important of all, whether the patient – the boxer – is recovering from the effects of concussion. There is therefore absolutely no thought of preventing concussion. What we wish to do by skillful clinical monitoring is to minimize the chance of tissue damage. “Concussion is not necessarily tissue damage but can lead to it. Our job, therefore, is to permit concussion but to minimize the damage. There is, of course, no guarantee that a hard single blow delivered in the right way, in the right time, at the right place can tear a brain apart. But the odds on that are infinitesimal. The usual tissue damage that takes place in boxing is the result of repeated severe blows to the head. If this sequence may be interrupted, tissue damage can be prevented.” “Everybody is familiar with somebody who has seen a match in which there did not seem to be awfully severe concussive head injury occurring, but, yes, a number of mini-concussions occurred, only to discover that the boxer doesn’t remember the last two rounds. And Recognizing the “Mini- Concussion”
lips relax, we are looking at laxity of muscle tone, and this may have meaning. We’ve all seen a fighter’s mouthpiece go flying out of his mouth. That could be the result of a direct blow to the mouth, but usually it means the impact is hard enough to cause a mini-concussion, with a very brief loss of being able to clench the jaw. The relaxation of the lips has allowed slippage of the mouthpiece. “When a boxer exhibits questionable motor behavior, watch how they dance, watch how they walk. If it’s at the end of the round, that’s one of the key times to watch. Do they know exactly where the corner is, do they turn to it promptly, and do they walk there in a smart manner. If we could concentrate on the tie-in of motor enervation with consciousness, then we can all come together on what the observations are that we should be making. “During the fight you have a chance to familiarize yourself with both boxers throughout the entire bout, and you’ll be able to see if fatigue is occurring in a gradual or a linear manner, or whether the fatigue seems to be a very new or very abrupt thing. This can be coupled with other observations as to how much riding, coasting and clinching is occurring. “A boxer rising from a knockdown must be quickly evaluated by the referee. It is not enough just to observe the boxer standing up, which is very low automatic behavior. A recommendation that you might entertain is under those circumstances make the boxer walk to the referee. Mention one simple little instruction to see what happens. “So, the purpose of this trauma course is not really so much to teach you what concussion is all about – although that’s central – it is to get across the vulnerability period of time.
The concept of ‘micro-concussions’ or ‘mini-concussions’ lasting just a few seconds and with incomplete loss of consciousness is very important because these comprise the overwhelming majority of what will be seen as a hint in terms of the physiological basis for procedure. [In other words, recognizing the physical clues that motivate the referee or doctor to act accordingly.] One might be safe in indicating that the occurrence of a one-second micro- concussion probably is no reason to become excited or alarmed or do anything but note it. Where one draws the line between a half-second micro- concussion and a 10-second KO is of course very much a matter of individual clinical judgment on the part of the ringside physician and the referee. “What I think matters as much as the duration of an individual mini- concussion is how many of them there are in that round, and how many have occurred in the preceding rounds. I think that it’s not just the duration of the individual event but whether there’s been a series of events. Between rounds, you do have the availability to test speech and mental behavior. The first thing that is critical is with every round, no matter what you’ve seen or not seen, watch that man go back to the corner. You watch that boxer. And you must see for yourself if he knows exactly where to go and goes there. Is he alert or glassy-eyed? Is he slumped all over or is he sitting there with good muscle tone [meaning good posture even while sitting, indicating alertness]. Should there be any question in your mind, you’ve got 60 seconds to do something about it, and you probably should only take 30 of those seconds. You should ask him simple, oriented questions [as described in the next paragraph]. The fact that the
fighter may know his name, place and time by no means proves that his mental function is normal. If he doesn’t know his name, place and time, right away you’re dealing with someone who’s had a pretty severe concussion and is not yet recovered from it.” Asking the Right Questions “Last of all, there is what might be called the integrative, or innovative, or new or non-learned acts. If he’s been in this particular boxing arena many times, you don’t say, ‘Where are you?’ He takes one look around and says, ‘I’m in a boxing ring.’ That is not really the issue. The issue is to ask for new behavior – such as ‘How many dimes are there in a dollar?’ Or ‘Touch your left hand three times against your right knee.’ If that direction can be understood quickly and the response correctly carried out quickly, that person, if he had a concussion, has fully recovered from it. “It should always be kept in mind that the original language goes last and that somebody may be able to respond in Spanish while partly concussed and not be able to speak in English. So if before the fight you know that he has learned English, talk to him in English when you examine him. If you need to talk to him during the fight, you’ll immediately discover whether there’s been any decay. You need to know the baseline level; this just takes a minute or two visiting the boxer in his dressing room before the fight. Is this a person who always thinks over an answer for two minutes before he answers? There are slow people. I think it’s helpful to know not necessarily how many grades of high school the fighter might have had, but certainly in conversation with him to see for yourself how he behaves with simple questions and answers, and that may give you all the information you need at a subsequent time because you have something to compare with.” When in Doubt, Stop the Bout (Hamilcar Publishers) is the latest book by boxing historian and author Mike Silver.
“Concussion is not necessarily tissue damage but can lead to it. Our job, therefore, is to permit concussion but to minimize the damage.”
there’s been some clinical research now that’s established that such infinitely coordinated activity as playing a violin in a concert can be done with less than complete consciousness. So, the simple fact that somebody stands, walks, moves, goes through earlier-learned, well- rehearsed movements proves nothing. You must see good muscle tone, sharp performance, good coordination, nice speed, no fall-off in performance. If there is a fall-off in performance, certain abilities are affected, such as seeing an incoming blow quickly and reacting to it quickly and in time. The ability to duck, bob, weave, turn, give with it, stiffen your neck muscles to absorb the impact – all of these things do not work efficiently when you’re in a state of partial concussion or recovery from a partial concussion. “The direct news I’m trying to get across is that a boxer who is in the middle of a mini-concussion is defenseless. Now, he may not be a ‘rag doll’ down on the floor, but he cannot pick things off that are coming in; and it is this phase, with the inability to protect by stiffening the body, by stiffening the neck and avoidance behavior, where the real brain damage may come. Put another way, a blow that the normal boxer in complete health could handle perfectly capably, under the circumstances I’m describing he may not be able to protect from it capably – and the amount of energy delivered to the head would be more. In that state, the boxer is vulnerable to a whole series of punches.”
the motor performance of the boxers. So that you look to see if somebody is no longer making nicely coordinated moves, but is merely making simple, stereotyped moves. A great number of the so-called ‘slips’ that you see may be slips; an equally great number of those are not true slips; they’re somebody who for just a split second lost enough consciousness that the tone of their muscles and the coordinative capacity of their legs got interrupted. Instead of there being a complete fall on the floor, there is a momentary slip. In some instances when somebody receives a blow, you can see their knees buckle, just a little bit. This is one of the reasons that it’s very important wherever possible to keep boxers off the ropes and out of the corners, because this robs you of some of your most key observations. You can see, for example, how if somebody is up against the ropes and has a concussive blow and the knees slump, the boxer does not go on the deck; he is already up against the ropes, and you may or may not be able to be certain what’s happening. “Questionable motor behavior to be aware of includes how the fighters clinch. There is a difference between an observed, goal-directed clinch and somebody who is slumped and is using the other man like a hitching post. It may not last long, but it is one of the signs of a concussion. At such moments, the TV ringside commentator will say, ‘He’s in trouble, he’s hurt!’ What they are doing is actually describing the effects of a concussion.” Laxity of Muscle Tone “Another example of motor enervation is that although some fighters do not fully close their lips around their mouthpiece, most boxers do. If, after several rounds, the boxer is showing no mouthpiece and then starts to have his
Questionable Motor Performance
“When a boxer exhibits questionable motor behavior, watch how they dance, watch how they walk.”
“The key linkage between full consciousness and full alertness as observed in the ring (where you cannot exactly sit down and do a lengthy interview) is gauged exclusively from
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