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Systematic review · Preprint · Combat Sports Regulation and Science · 2026

Standardized Post-Bout Ringside Concussion Screening in Combat Sports
Systematic Evidence Review and Development of the RACE1 Ringside Acute Concussion Examination

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Casey C. Sears · ORCID iD 0009-0000-6344-1143 · ISNI 0000 0005 3070 820X · Commissioner, Alabama Athletic Commission; Chair, Rules and Procedures Committee; Chair, Medical Oversight Committee; Principal Investigator, AAC Combat Sports Health and Safety research project.

Preprint, not peer reviewed. Released to seek co-authors and initial peer review before journal submission.

Download complete PDF (84 pages) RACE1 cards Cite

Bibliographic record

DOI
https://doi.org/10.67999/csx.003
Author
Casey C. Sears · ORCID 0009-0000-6344-1143 · ISNI 0000 0005 3070 820X
Affiliation
Alabama Athletic Commission, Alabama, USA
Correspondence
editor@searspublishing.net
Type
Systematic review with instrument development (preprint, not peer reviewed); Crossref 5.5 report-paper record
Published
October 1, 2026
Publisher
Sears Publishing Company, Tuscaloosa, Alabama, USA · ISNI 0000 0005 3070 8218
Series
Combat Sports Regulation and Science
Report number
CSX-003
Version
1.0
Extent
84 pages; 116 references; 10 figures; 10 tables; Appendix C reproduces the 18 RACE1 cards
Supplementary file
S7, RACE1 card deck (edition 4): https://doi.org/10.67999/csx.003.s7
Language
English
Rights
Copyright © 2026 Sears Publishing Company. All rights reserved. Free to read.
Permanent URL
https://combatsports.searspublishing.net/articles/csx-003/
Keywords
boxing, concussion, sideline assessment, combat sports, ringside physician, mixed martial arts

Abstract

Context. The objective was a standardized post-bout ringside concussion protocol for combat sports regardless of rule set: professional boxing, mixed martial arts (MMA), bare-knuckle boxing, kickboxing, Toughman contests, amateur MMA and amateur boxing. Amateur boxing was the model for its stricter rules (mandatory post-bout examination, Sport Concussion Assessment Tool after a knockout or head-blow stoppage, tiered restrictions).

Evidence Acquisition. PubMed/MEDLINE, Consensus, Scholar Gateway, Wiley Scholar Gateway, SciSpace, alphaXiv and ClinicalTrials.gov were searched on September 30, 2026, without limits, plus citation searching. One reviewer screened and extracted; the author verified a 10% sample. Synthesis followed the Synthesis Without Meta-analysis guideline.

Study Design. Clinical review (systematic search with synthesis without meta-analysis) and instrument description.

Level of Evidence. Level 3.

Results. Of 2,250 records, 2,063 were screened and 214 core records were included (53 amateur); 137 rested on the abstract. Of 33 primary studies judged on full text, 16 were at high risk of bias. No amateur study measured the accuracy or reliability of any ringside item; nothing was pooled. Diagnosed concussion was recorded infrequently with incompatible denominators, stoppage could not substitute for diagnosis, and an abstract reported evolving cognitive slowing after 2 of 160 bouts in boxers not suspected at ringside. In other sports, single components were mostly specific, with limited sensitivity. Amateur evidence for every screening item was SORT Level 3. RACE1 is an 18-card post-bout screen, compared with a pre-bout baseline where possible, scored out of 20, with 3 provisional dispositions.

Conclusions. A multidomain post-bout screen can standardize ringside findings, but a normal screen cannot exclude concussion. RACE1 is used only after the bout and never clears an athlete or permits same-day return. Evidence is mainly from amateur boxing; RACE1 has not been evaluated in any sport.

Strength-of-Recommendation Taxonomy (SORT). After the bout, any sign, symptom or examination deficit precludes a "no deficit detected" result; absence of signs does not exclude concussion (B). Use brief items from several domains, never one domain alone (B). Transport any boxer with a red flag to a pre-identified trauma center with computed tomography and neurosurgical cover (C). A normal screen is not clearance (C).

Role of the RACE1 cards

The RACE1 cards are intended to give the ringside clinician structured guidance after the bout. They do not supersede the authority, clinical judgment or decisions of the ringside physician or any other licensed ringside clinician, and they do not replace the rules or medical requirements of the governing body. Whether to stop a bout, whether to transport, and whether and when an athlete is cleared remain decisions of the ringside physician.

RACE1 is used only after the bout, against a pre-bout baseline where possible. It is never used during a bout, between rounds, or to permit return to participation the same day or in the same competition. A normal result is not a clearance. The items and score bands are provisional and have not been validated in any sport. The complete deck (edition 4) is reproduced in Appendix C of the PDF for review.

Supplementary File S7. The complete RACE1 card deck (Appendix C) is also issued as a standalone document with its own DOI: RACE1 Ringside Acute Concussion Examination Card Deck (Edition 4): Supplementary File S7 · https://doi.org/10.67999/csx.003.s7.

Complete article

The complete 84-page preprint, including the methods, the component-by-component evidence synthesis, risk-of-bias and certainty assessments, 10 figures, 10 tables, 26 graded clinical recommendations, the exact search strings (Appendix A), reports not retrieved (Appendix B), the RACE1 cards (Appendix C) and all 116 references, is available in the PDF.

Declarations

Author declarations / competing interests. Casey C. Sears serves as an appointed Commissioner for the Alabama Athletic Commission (AAC) and Principal Investigator for the AAC Combat Sports Health and Safety research project. He is the original developer of the RACE-1 and HTRP ringside medical protocols discussed in this manuscript. The author is also the founder of Sears Publishing Company, which serves as the distributor of this preprint.

Funding. None.

Use of artificial intelligence. This article was produced with the assistance of AI through an LLM. Any questions related to its use should be directed to editor@searspublishing.net.

Invitation to collaborate and review

This preprint has not been peer reviewed. Clinicians, ringside physicians, athletic trainers, researchers and regulators are invited to comment on the evidence review, the RACE1 cards and the validation agenda, and to express interest in co-authorship or multi-site validation, at editor@searspublishing.net. Please cite the section, table, figure or card number.

How to cite

Sears CC. Standardized Post-Bout Ringside Concussion Screening in Combat Sports: Systematic Evidence Review and Development of the RACE1 Ringside Acute Concussion Examination [preprint, not peer reviewed]. Sears Publishing Company; 2026. Report No. CSX-003. doi:10.67999/csx.003.

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