http://ajs.sagepub.com/Medicine

The American Journal of Sports

http://ajs.sagepub.com/content/42/7/NP43The online version of this article can be found at:

DOI: 10.1177/0363546514539633 2014 42: NP43Am J Sports Med

Marla WarnerHead Trauma in Mixed Martial Arts: Letter to the Editor

Published by:

http://www.sagepublications.com

On behalf of:

American Orthopaedic Society for Sports Medicine

can be found at:The American Journal of Sports MedicineAdditional services and information for

http://ajs.sagepub.com/cgi/alertsEmail Alerts:

http://ajs.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

What is This?

- Jun 30, 2014Version of Record >>

by guest on July 25, 2015ajs.sagepub.comDownloaded from by guest on July 25, 2015ajs.sagepub.comDownloaded from

Head Trauma in Mixed MartialArts: Letter to the Editor

DOI: 10.1177/0363546514539633

Dear Editor:A recent article in The American Journal of Sports Med-

icine entitled Head Trauma in Mixed Martial Arts, writ-ten by Michael G. Hutchison, David W. Lawrence, MichaelD. Cusimano, and Tom A. Schweizer,5 is about a criticallyimportant topic that deserves our undivided attention.Mixed martial arts (MMA) shows a recent increase in pop-ularity and is a full combative sport with a high rate ofinjuries, particularly head injuries.5 This sport is growingtremendously in amateur and youth categories. There islimited research on head trauma in MMA. I feel that it isvery important to research the mechanism and seriousnessof injuries related to the sport of MMA, particularly whenyouth are involved. I think that it is more important tobegin taking greater measures to protect MMA competitorsfrom traumatic head injuries. Hutchison et al5 discuss theincidence, risk factors, and characteristics of knockouts(KOs) and technical knockouts (TKOs) due to repetitivestrikes in MMA. A KO is defined as occurring when a com-petitor is knocked down unconscious or disoriented, anda TKO is defined when a referee stops the contest whena competitor is disoriented to the point where he or sheis unable to defend himself or herself.5 What I am mostinterested in is what is being done to prevent head traumain MMA. Mixed martial arts includes techniques froma variety of sports including boxing, wrestling, karate,taekwondo, jujitsu, Muay Thai, judo, and kickboxing. TheAmerican Medical Association (AMA) describes MMA asviolent and dangerous and expresses its concerns aboutthe aggressiveness of the sport and it causing physicalharm, specifically brain injuries.5 A comparison wasmade between match scorecards and digital video record-ings of matches. Conclusions showed that rates of headinjuries in MMA are higher than those reported in boxing.This is shocking to me! In a video analysis of 65 KOs, thehead was the part of the body struck in all 65 events.5(p3)

Of the 65 competitors who lost by a KO, 41 (63.1%) sus-tained a secondary head impact with the fighting environ-ment (ie, the floor, cage, or post).5(p4) Of these 41, 37competitors (90.2%) struck the arena floor, most frequently(n = 30, 73.2%) impacting the occipital region of thehead.5(p4) The specific region of the head that was struckwas the mandible (35 events [53.9%]), followed by themaxillary (13 events [20.0%]) and temporal (13 events[20.0%]) regions.5(p3) Public health officials and physiciansshould be educating participants and patients appropri-ately about the risk of brain injuries associated with KOsand TKOs from repetitive blows to the head.5 Physiciansand/or athletic trainers should be present especially at

competitions and should also have increased trainingand/or ringside tests to perform on competitors. Theseassessment tools will better help to decide whether compet-itors have suffered severe head trauma and should con-tinue the match or not.

This topic is of great interest to me because my 9-year-old son just began taking jujitsu classes. His class includessome Thai kickboxing as well. When he initially began hisclasses, I was very concerned for his safety. I am thankfulthat he enjoys the jujitsu (wrestling) style more so than theboxing style. However, I am finding that chokeholds on theneck, frequently performed in jujitsu, can be just as dan-gerous as blows to the head. There is an article to supportthis entitled After Injury Leaves Him Paralyzed, an MMAFighter Battles Still in The Sacramento Bee.3 DevinJohnson, an MMA competitor, was paralyzed by a choke-hold performed on him during a match. This article dis-cusses his story of injury through rehabilitation.

The article published in this journal relates to healthcare because private health care insurance costs are cur-rently so high that a traumatic injury sustained in MMAcould end up costing a significant amount of money overthe course of a lifetime. Repetitive injuries to the headfrom MMA-style competition could lead to many expensivemagnetic resonance imaging (MRI) and/or computedtomography scans over a period of time. If such severehead trauma occurs, the competitor could even requirecare for the rest of his or her life. This would lead to signif-icant medical costs. Current government insurance maynot provide you with the best medical treatment becauseof how the injury occurred. Insurance companies havebeen creative in finding ways to eliminate subscriberswho might be costly.6(p1) This could be a huge problemfor competitors who are not willing to give up the sport.If they are dropped from an insurance company, theymight have difficulty in finding another one to pick themup. Then, they may also have trouble with coveragebecause of having a pre-existing medical problem.

The King-Devick test (K-D test) is an evidence-basedpractice that is being utilized ringside to determine if a con-testant has suffered severe head trauma due to repetitiveblows to the head.2 This test is based on measurement ofthe speed of rapid number naming, and it also recognizesimpairment of eye movements, attention to the practitioner,and language. It is administered before and after a fight,and any differences are compared.5 The K-D test is accurateand reliable in identifying head trauma in MMA fighters.5 Ithink that this is a good test to start providing more regu-larly not only at competitive matches but also at practices.

Dr Charles Burnick stated that there really is no objec-tive way to decide when a person should stop fighting ornot be licensed to fight.5(p2) Some people say that manda-tory MRI of all brain-injured competitors should be consid-ered to avoid further head trauma.5 There is an estimatedaverage of 2 to 3 strikes to the head after a KO. Competi-tors would benefit from greater protection by referee inter-vention to avoid this.5 There is a definite urgency instopping competitive fights before severe head traumatakes place. It is, however, a difficult job of the refereesto decide when an athlete is incompetent to continue

The American Journal of Sports Medicine, Vol. 42, No. 7 2014 The Author(s)

NP43 by guest on July 25, 2015ajs.sagepub.comDownloaded from

fighting because of repetitive blows to the head. KeithKizer, executive director of the influential Nevada StateAthletic Commission, said medical research on MMA haslong been lacking, in part because doctors have typicallyspurned the sport.4(p5) Kizer also recommended thata national medical registry be available. However, thiswould break HIPAA (Health Insurance Portability andAccountability Act of 1996) laws, and it would be verycostly. Hutchison et al5 recommended that when fightersappear disoriented, they should be given a count of 10 sec-onds, similar to boxing, to allow the referees time to evalu-ate if they feel that they can continue competing.Hutchison et al5 also felt that a policy should be put intoplace that athletes must undergo a complete medical exam-ination after a KO or TKO before returning to training.Both articles agree that further research is required toreduce head trauma in MMA.

I would like to see physicians and public health figureseducate patients and participants in MMA more in depthabout the risk factors of severe head trauma. Refereesshould also be required to have additional training in rec-ognizing earlier when a competitor suffers a concussion. Itmay cost MMA-related organizations more money to edu-cate and perform increased precaution techniques for thesafety of competitors; however, they could avoid possiblelawsuits and high insurance costs later after a traumatichead injury has occurred because these efforts were notput into place. I feel that it would benefit MMA competitorsto have trained physicians and/or athletic trainers ring-side, who understand the mechanism of head trauma andknow how to perform the K-D test. I truly feel that thiswould prevent further and more severe head trauma inthe future. I personally would like to see greater

preventative steps taken, because of my sons love of thesport of MMA, to avoid head trauma in MMA.

Marla WarnerUtica, New York, USA

Address correspondence to Marla Warner (e-mail:

mwarner@svcsd.org).

The author declared that she has no conflicts of interest in theauthorship and publication of this contribution.

REFERENCES

1. American College of Sports Medicine. Injuries in emerging sports calls

for improved medical understanding [news release]. August 1, 2011.

Available at: http://www.acsm.org/about-acsm/media-room/acsm-in-

the-news/2011/08/01/injuries-in-emerging-sports-calls-for-improved-

medical-understanding. Accessed April 6, 2014.

2. Galetta KM, Barrett J, Allen M, et al. The King-Devick test as a deter-

minant of head trauma and concussion in boxers and MMA fighters.

Neurology. 2011;76(17):1456-1462.

3. Gutierrez M. After injury leaves him paralyzed, an MMA fighter battles

still. The Sacramento Bee. March 31, 2013. Available at: http://

www.sacbee.com/2013/03/31/5305129/after-injury-leaves-him-para

lyzed.html#storylink=cpy. Accessed April 6, 2014.

4. Harris S. A sense of urgency: MMA races to learn more about brain

injuries. Bleacher Report. May 8, 2013. Available at: http://bleacherre

port.com/articles/1633111-a-sense-of-urgency-mma-races-to-learn-

more-about-fighter-brain-injury. Accessed April 6, 2014.

5. Hutchison MG, Lawrence DW, Cusimano MD, Schweizer TA. Head

trauma in mixed martial arts. Am J Sports Med. 2014;42(6):1352-1358.

6. Welsh T. Whats wrong with American health care? The Seeker Books.

2011. Available at: http://www.theseekerbooks.com/articles/Whats

Wrong.html. Accessed April 6, 2014.

For reprints and permission queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav

NP44 Letter to the Editor The American Journal of Sports Medicine

by guest on July 25, 2015ajs.sagepub.comDownloaded from

/ColorImageDict > /JPEG2000ColorACSImageDict > /JPEG2000ColorImageDict > /AntiAliasGrayImages false /CropGrayImages false /GrayImageMinResolution 150 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict > /GrayImageDict > /JPEG2000GrayACSImageDict > /JPEG2000GrayImageDict > /AntiAliasMonoImages false /CropMonoImages false /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict > /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox false /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (U.S. Web Coated \050SWOP\051 v2) /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /Unknown

/CreateJDFFile false /Description > /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ > > /FormElements true /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MarksOffset 6 /MarksWeight 0.250000 /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PageMarksFile /RomanDefault /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /LeaveUntagged /UseDocumentBleed false >> ] /SyntheticBoldness 1.000000>> setdistillerparams> setpagedevice