Concussions are one of the most misunderstood injuries in sport. They are invisible on standard imaging, variable in presentation, and consequential when mismanaged. In combat sports; where the entire objective can involve intentional contact to the head; understanding concussion science is not optional. It is a fundamental responsibility for every fighter, coach, and corner person in the gym.
What Is a Concussion?
A concussion is a traumatic brain injury caused by a biomechanical force; typically a blow to the head, face, or neck, or a force transmitted to the head through the body. It results in a complex pathophysiological process affecting the brain, characterized by a range of functional disturbances rather than structural damage visible on MRI or CT scan.
This is critical to understand: a concussion is a functional injury, not a structural one. That is why athletes often look fine after a concussion; because standard scans are normal. The injury is metabolic, involving ion flux disruptions, altered neurotransmitter release, and a temporary mismatch between energy demand and cerebral blood flow.
Concussions do not require loss of consciousness. In fact, the majority of concussions in sport occur without any loss of consciousness at all.
Immediate Recognition: The SCAT5 Tool
The Sport Concussion Assessment Tool (SCAT5), developed from the consensus guidelines published in the British Journal of Sports Medicine, is the most widely validated sideline assessment tool for concussion in athletes aged 13 and older. (BJSM Concussion Consensus Statement, 2017)
Key SCAT5 components include:
- Symptom checklist: Headache, pressure in the head, neck pain, nausea or vomiting, dizziness, blurred or double vision, balance problems, sensitivity to light or noise, feeling slowed down or in a fog, difficulty concentrating, memory problems, fatigue, mood changes
- Orientation questions: Date, month, year, day, and current venue
- Standardized Assessment of Concussion (SAC): A brief cognitive screen covering orientation, immediate memory, concentration, and delayed recall
- Balance Examination (BESS): Assesses postural stability across three stances
- Neck examination: Cervical spine assessment to rule out associated injuries
The key principle of the SCAT5 is simple: when in doubt, sit out. Any athlete suspected of sustaining a concussion should be immediately removed from play and not return on the same day, regardless of symptom resolution.
Red Flags Requiring Emergency Care
Several presentations following a head impact require emergency evaluation rather than standard concussion management:
- Seizure or convulsive activity
- Loss of consciousness longer than a few seconds
- Worsening headache that is intensifying over time
- Repeated vomiting
- Increasing confusion or agitation
- Deteriorating neurological status
- Neck pain with neurological symptoms (numbness, tingling, weakness in limbs)
Any of these symptoms should trigger immediate emergency services activation, not a sideline assessment.
Return-to-Sport Protocol
The standard return-to-sport (RTS) protocol is a six-stage graduated process that must only begin after the athlete is completely symptom-free at rest. No athlete should attempt return-to-sport while symptomatic.
The stages are:
- Symptom-limited activity: Daily activities that do not provoke symptoms
- Light aerobic exercise: Walking, swimming, stationary cycling; no resistance training or high heart rate
- Sport-specific exercise: Running drills, footwork, pad work at low intensity; no head impact
- Non-contact training drills: More complex training, resistance training may begin
- Full-contact practice: Normal training after medical clearance
- Return to competition
Each step should take a minimum of 24 hours. If symptoms return at any stage, the athlete drops back to the previous stage and rests until symptom-free again before progressing.
Cognitive vs. Physical Rest Balance
Early concussion management traditionally emphasized strict cognitive and physical rest. Current consensus has evolved: brief initial rest (24-48 hours) is appropriate, but prolonged strict rest is no longer recommended and may actually slow recovery.
After the initial 24-48 hour period, light sub-symptom-threshold aerobic activity has been shown to promote recovery by improving cerebral blood flow and reducing symptom duration. The goal is activity that does not worsen symptoms; not complete inactivity.
Cognitive demands (screen time, intense reading, stressful work or school environments) should be reduced in the early recovery period and reintroduced gradually as symptoms allow.
Second Impact Syndrome and Cumulative Risk
Second impact syndrome (SIS) is a rare but potentially catastrophic condition in which a second concussion occurs before the brain has fully recovered from the first. The result can be rapid, severe cerebral swelling due to loss of autoregulation of blood flow. SIS has been associated with deaths in young athletes.
Even without SIS, cumulative concussion exposure is a serious concern. Repeated concussions are associated with longer recovery times, lower thresholds for future injury, and long-term neurological changes. For combat sports athletes, where head contact is inherent to the sport, this cumulative risk demands rigorous protocol adherence; not shortcuts.
Fighters and coaches must understand that no competitive outcome is worth a permanent neurological consequence. The return-to-sport protocol exists because the short-term cost (time away from competition) is far smaller than the long-term cost of a mismanaged head injury.
Building a Culture of Safety
The most effective concussion management happens before the injury; through a gym culture where athletes feel safe reporting symptoms, coaches are trained in recognition and protocol, and nobody is pressured to “tough out” a head injury. That culture starts with education and is reinforced by the standards you set and model every time you step into the training environment.
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