Written evidence submitted by England Boxing, Boxing Scotland, Welsh Boxing, GB Boxing and the British Boxing Board of Control
Boxing Governing Bodies Submission
Written Submission to the Digital, Culture, Media and Sport Select Committee Inquiry into Concussion in sport
2 April 2021
Dear Mr Knight,
Re: Boxing governing bodies written submission to the Digital, Culture, Media and Sport Select Committee Inquiry into Concussion in Sport
Following a discussion with the Select Committee Clerk on the 25th March 2021, we are delighted to have the opportunity to submit a written response to the inquiry into concussion in sport and are grateful to the Committee for allowing us to submit our response by Friday 2nd April 2021. We look forward to discussing our submission at a possible third oral evidence session after the Easter Recess.
We are the governing bodies representing professional and amateur boxing in the United Kingdom including England Boxing, Boxing Scotland, Welsh Boxing, GB Boxing and the British Boxing Board of Control.
Our Statement of Purpose is to work together to make the positive case for boxing to ensure that it is well placed to grow and flourish as the United Kingdom emerges from the Pandemic and to promote the benefits of boxing at all levels from grassroots to the elite in the countries of the United Kingdom.
Creating a safe environment for professional and amateur boxers through effective regulation.
The governing bodies have developed an effective regulatory framework for boxing that has created a safe environment for professional and amateur boxers, ensuring that all participants from the elite to the grassroots reap the many physical and mental health benefits of our sport.
Promoting social inclusion, positive mental health and well-being will be key policy objectives as the United Kingdom emerges from the Pandemic, and boxing is well-placed to support such ambitions as it can reach deep into diverse communities, and appeals to men and women, young people and adults. Boxing offers so much more than just a space to train and is a vital part of our nation’s social fabric. Clubs not only provide pastoral and educational support to young people and adults in need, but also help to promote social inclusion, tackle criminal activity and antisocial behaviour, and deliver improvements in physical and mental wellbeing.
The governing bodies have worked hard to ensure that the best medical advice and support is available to professional and amateur boxers, and that all coaches and officials have a deep understanding of the risks of head injury and the long-term impacts of concussion. Our regulated sport has developed a rigorous approach to head injury and concussion, and this is in direct contrast to unregulated white-collar boxing. We urge the Committee to seriously consider the status of white-collar boxing as in our view such action would help to reduce the risk of head injury and concussion for those taking part in unregulated events.
All professional and amateur boxers are carefully matched according to weight and experience as this leads to a safer contest. Interestingly, research carried out by RSPoA (Royal Society of prevention of Accidents) showed that 28 other sports were more likely to result in injury than professional and amateur boxing, and 36 other sports were more likely to result in death than professional and amateur boxing.
Professional boxers stopped in a bout are suspended for 28 days (including a complete ban on all gym activities), rising to 45 days if they are physically knocked out or have suffered blows to the head and upper body. Medical advice can also increase the suspension period to up to 6-months if required.
After their suspension period has completed, they must receive clearance to spar again from the British Boxing Board of Control (BBBofC). This rigorous concussion assessment is carried out by qualified BBBofC doctors and can involve an MRI brain scan in extreme circumstances (alongside the routine annual brain scan required from all professional boxers).
Professional and amateur boxing has been at the forefront of concussion prevention for some time. A minimum of at least two doctors are required to attend each professional contest but this could increase depending on the size of the venue with at least one fully equipped paramedic ambulance crew on standby in case of severe head trauma. Referees and bout officials are well trained in the appropriate processes and are extremely quick to react when a boxer is in obvious distress following a blow to the head, reducing the likelihood of a potentially life-changing secondary impact.
The thorough, effective and comprehensive safety regulations governing both professional and amateur bouts mean that young boxers are significantly less likely to suffer the consequences of repeat concussion.
Specifically, on the main areas you have requested feedback on during the consultation period we would ask that you consider the following points:
Role of national governing bodies in ensuring member clubs receive up to date medical advice and promote good practice.
With the help of leading neurosurgeons and expert medical advisers, the BBBofC has developed an innovative, rigorous and comprehensive concussion assessment framework that proves that erring on the side of safety can make all the difference in safeguarding the cognitive well-being of young male and female boxers.
Medical Handbook setting out national standards.
The BBBoC has produced a detailed Medical Handbook that highlights the role of the ringside physician/Medical Officer, describes various medical conditions encountered ringside and explains how they should be managed. The guidance is based on national standards of best practice and medical expert advice on the treatment of boxers in an out-of-hospital environment.
At each professional contest, there will at least be two doctors present (and often more depending on the size of the tournament) including at least one anaesthetist (or other physician with advanced airway skills and currently competent in the management of an unconscious casualty). A lead doctor will be nominated who will assign individual roles/duties for the show. It is important to note that an anaesthetist is required to be always at ringside during a professional bout.
Pre and post contest medicals
Before any professional contest, each boxer must undergo a pre-contest medical, a focused examination to ensure that the boxer is well and able to compete on the night. The boxer’s “fitness to box” is a medical decision, which is final. At the end of each bout, medical officers must get up on the ring and briefly examine the boxer to ensure that they are fit to leave the ring. If there has been a stoppage/knockout, the doctor may need to get into the ring to assist/examine the boxer. Once the boxer has arrived back in the dressing room, a more thorough assessment is conducted to assess for any head or musculoskeletal injuries.
In the event of a contest being stopped by a referee (other than disqualification), or a boxer retires during the contest, or a boxer is counted out during a contest then a minimum 28-day licence suspension is imposed. This can be extended up to 45 days or longer at the discretion of the Senior Medical Officer present at the tournament. Should a boxer require further assessment and/or management in hospital and the boxer ignores this advice, the BBBofC will suspend the boxer’s licence.
The BBBofC has also produced a detailed Concussion, Head Injury, and Facial Laceration advice card providing advice and guidance on warning signs and treatment that is given to every boxer after a professional bout. See Appendix 1.
Annual medical assessment and MRI report
Every professional boxer must also undergo an annual medical assessment with a qualified medical practitioner registered with the General Medical Council at the time of application for a professional licence or annually when the licence is due to be renewed. Furthermore, all professional boxers should submit a satisfactory MRI brain report annually and all boxers must have an MR Angiogram at their time of first application. Every medical is reviewed by BBBofC head office doctors and will only be signed off when all information is correct and in order.
Management of boxers with concussion
Boxers diagnosed with concussion are given a mandatory 28-day suspension and are not left alone for 48 hours following a bout; and are given head injury advice by expert medical staff. Medical and supportive advice is also explained to the boxer’s management and coaching team too.
The boxer will be told to physically and mentally rest, not to consume alcohol, not to take prescription or non-prescription drugs without medical supervision and not drive/play sport until medically cleared. The boxer is also advised that if they experience any new signs or symptoms, they must present to their nearest emergency department.
Most concussions will resolve within 10 days. However, if a boxer returns to training too early then they may prolong symptoms, expose themselves to second impact syndrome and experience long term consequences. It is emphasised to boxers in the strongest possible terms that rest is the most important treatment of concussion. This means physical and mental rest.
Return to action protocol.
Professional boxing has adopted an innovative and effective return to action protocol that other sports can and should adopt. For example, to return to action, a boxer must be symptom free for 2 weeks before any activity can be undertaken. The return to activity is considered on case-by-case basis and a formal medical assessment is required. For example, during the period January – November 2020 the BBBoC received 26 neuropsychological assessment applications, approved 16 and declined five applications. Four assessment reports were not received, and one assessment application was withdrawn.
Following successful assessment by a medical practitioner a graduated return to training is progressed. This involves light aerobic activity initially then progressing to moderate activity and normal training activities. The progression through each stage is dependent on being symptom free for 24 hours at each stage. If the activity is not symptom free, then a minimum of 24 hours rest must be undertaken, and medical advice sought until the next stage can commence. If complications in recovery are encountered then specialist assessment by a neurologist, cross sectional imaging of the brain and neuropsychological assessment may also be required.
Amateur boxing through its federations is highly regulated, and all boxers need a thorough medical before they can take up sparring or competitive boxing, and they then have an annual medical, and a medical check every time they box. Furthermore, just like the professional boxers, in amateur boxing a bout at any level cannot start unless the doctor is present at ringside.
As a contact sport, amateur boxing is extremely safe with the same concussion rate as ice skating. Recent research conducted in Australia that examined concussion rates across various sports showed that an athlete is 500 times more likely to be concussed playing Australian rules football than taking part in amateur boxing. Furthermore, a systematic review into observational studies of amateur boxing and risk of chronic traumatic brain injury by Professor Mike Loosemore, Charles H Knowles and Greg P Whyte published in the BMJ (4th October 2007) concluded that current evidence for chronic traumatic brain injury as a consequence of amateur boxing was not strong.
Coaches and officials at amateur boxing clubs are also trained to a high standard meaning they can react quickly and effectively to possible head injury and concussion incidents. Of course, this risk is further mitigated because boxers are carefully matched according to their weight and experience.
Tight medical regulation
All the governing bodies abide by the medical rules set out in the Medical Commission of the International Boxing Association (AIBA) Medical Handbook and incorporate the guidance in their own rule books. In addition, Boxing Scotland has also taken guidance from sportscotland’s Scottish Sports Concussion Guidance (sportscotland.org.uk), including direction from their Medical Commission on pre- and post-bout guidance, along with head injury management. See Appendix 2.
The England Boxing Rule Book is a comprehensive guide that ensures that member clubs receive good medical advice and promote best practice. It details that boxers wishing to register with England Boxing must pass an initial medical and apply for a Boxer Competition Record on a Regional Register. A lost record will automatically result in a 30-day medical suspension. See Appendix 3.
A boxer must then undergo an annual medical to confirm if the boxer is “fit to box”. In addition, prior to each contest a boxer must receive a Pre-Bout Medical to ensure there are no changes to the “Fit to Box” status of the boxer from the time of the annual or initial medical. The result of the pre-bout medical is retained by the ringside physician for the duration of the competition. Following a bout, the boxer must then complete a “post bout medical” with the bout supervisor and ringside doctor. Medical suspensions are imposed on boxers that fail their post bout medical usually following competitive boxing to protect them from further injury. Minimum suspensions are set for specific incidents and all periods of suspension are determined by the ringside doctor and are not negotiable. Suspension terms range from 30 days to 18 months dependent on the nature of the incident.
Age-appropriate graduated return to boxing programmes following head injury and concussion.
The governing bodies have developed specific, detailed and “age appropriate” guidance for head injuries, concussion and return to boxing protocols including a six-step graduated return to boxing programmes for those aged 18 and under and 19 and older. We detail below key points from the graduated return to boxing programme for young people aged 18 years and under for your information:
18 years and under
To allow the brain time to fully recover and reduce the chance of any longer-term problem’s boxers should have a period of rest, with no training or playing sport, and then adjust activity for a period. The first step is to avoid all physical activity and any activities which require concentration or attention for 24-48 hours. This includes minimizing time using mobile phones or the internet for emails & social media, watching TV or movies, reading and all forms of training & exercise.
Phased return to school
Concussion can affect the boxer’s ability to learn, and mental activity may worsen symptoms and a return to school should be phased in gradually to ensure that the symptoms do not worsen. Boxers should not return to school sport until they have returned to full school / learning, without symptoms. A period of relative rest is advised for the remaining duration of the medical suspension (minimum 30 days).
Graduated return to boxing
Once the medical suspension has been completed (and the boxer has been symptom free for at least 2 weeks), they may move to ‘Step 2’ of the gradual return to boxing programme and begin light aerobic exercise. If the boxer can train at ‘Step 2’ without developing any symptoms for 48 hours, then they may move onto ‘Step 3’. The boxer must be symptom free for a period of 48 hours at each step before moving on to the next, higher level step. Prior to reaching ‘Step 5’ and returning to sparring, the boxer must see a doctor for a more detailed assessment and to gain medical clearance to safely return to full contact training.
As we have demonstrated, tight and rigorous regulation, effective training for coaches, and continual improving of the rules by the governing bodies has made amateur boxing a safe test of courage between two boxers of equal age, weight and experience, and allows participants to benefit from the many positive physical and mental health benefits of amateur boxing.
Funding for further scientific research
We would welcome the opportunity for the facilitation of more research into the impact and effects of concussion on female professional and amateur boxers.
Our sport has taken an innovative, comprehensive and rigorous approach to head injuries and concussion, ensuring that (1) member clubs receive up-to-date advice from their respective governing body and promote best practice and (2) amateur and professional boxers are not unnecessarily exposed to the damaging long-term impact of repeat concussion.
By developing a strong and effective regulatory framework we have been able to create a safe environment for professional and amateur boxers, allowing participants at all levels to take full advantage of the many physical and mental health benefits of boxing. We do however urge the Committee to consider the head injury and concussion risks of white-collar boxing and would be happy to work with the Select Committee, Government, and other interested stakeholders to consider the future status of this high-risk, dangerous and currently unregulated activity.
We hope that our written submission is helpful, and we would be happy to discuss these issues with the Select Committee during a possible third oral evidence session after the Easter Recess.
Gethin Jenkins, CEO, England Boxing
Chris Roberts, CEO, Boxing Scotland
Colin Metson, CEO, Welsh Boxing
Matt Holt, CEO, GB Boxing
Charlie Giles, Chairman, British Boxing Board of Control
Robert Smith, CEO, British Boxing Board of Control