Archive for the ‘Safety Studies’ Category

Adding to this site’s archives of combat sports safety studies, The Journal of Sports Health published a data review concluding that MMA combatants suffer an in competition injury rate between 22.9 and 28.6%.

In the recent study the authors reviewed 35 years of publications detailing injury rates in MMA or thier component sports.  The data revealed that “The majority of studies on MMA injuries evaluate those sustained during competition, which range in incidence from 22.9 to 28.6 per 100 fight-participations. Striking-predominant disciplines such as boxing, karate, and Muay Thai have high rates of head and facial injuries, whereas submission-predominant disciplines such as Brazilian jiu-jitsu, judo, and wrestling have high rates of joint injuries.

The study is titled “Injuries Sustained by the Mixed Martial Arts Athlete” and the full article can be purchased here.

In my latest review of safety studies in the world of combative sports, a recent article was published in the British Journal of Sports Medicine finding concussion ‘preventing’ sports equipment has ‘no effect’.
In the recent study, titled “Current State of Concussion Prevention Strategies: a systemic review and meta-analysis of prospective, controlled studies” the authors evaluated 14 studies reviewing the effects of “novel protective equipment“.  They concluded that while some equipment was effective in reducing “superficial head injury” (think cuts and bruises) when it came to concussion prevention the equipment “showed no effect of intervention“.

The study’s full abstract is reproduced below:

Abstract

Objective The aim of the current review was to systematically identify, evaluate and synthesise trials that examine concussion prevention via equipment, educational programmes and training programmes.

Data sources PubMed and EBSCO host (CINAHL, MEDLINE, SPORTDiscus).

Eligibility criteria for selecting studies The electronic databases PubMed and EBSCO were searched using the phrases: concussion prevention equipment, concussion prevention trainingand concussion prevention education. Included studies utilised a prospective study design to evaluate the preventative effect of: (1) equipment, (2) training or (3) educational programmes on the incidence of concussions in comparison to a control group.

Data extraction Demographic data and intervention methods were recorded. Intervention and control group concussion rates and superficial head injury rates were extracted and combined using random-effects relative risk meta-analysis.

Results 14 studies evaluated interventions of novel protective equipment. One prospective investigation evaluated an educational programme. The relative risk of concussion for participants enrolled in the interventional arms of trials was not significantly different from that in standard practice arms (RR=0.78, 95% CI 0.55 to 1.11, χ2=1.8, p=0.17; I2=85.3%, 95% CI 71.5% to 90.8%). The relative risk of concussion for participants wearing protective equipment (ie, headgear, full face shields) relative to their counterparts wearing standard or no equipment, calculated from seven available reports, showed no effect of intervention (RR=0.82, 95% CI 0.56 to 1.20, χ2=1.06, p=0.30; I2=86.7%, 95% CI 73.3% to 91.8%). The relative risk of superficial head injury for participants wearing protective equipment relative to their counterparts, calculated from three reports, showed a significant risk reduction (RR=0.41, 95% CI 0.31 to 0.56, χ2=34.13, p<0.0001; I2=53.1%, 95% CI 0% to 85.2%).

Conclusions Prospective controlled studies indicate that certain protective equipment may prevent superficial head injury, but these items are suboptimal for concussion prevention in sport.

Adding to this site’s archived summaries of studies addressing safety issues in combat sports, a recent study was published in the Journal of Neuroradiology canvassing the extent of objective white matter disturbance in the brains of amateur boxers compared to a control group.

The study, titled Reduced White Matter Integrity in Amateur Boxers, posed the question of whether amateur boxers would have white matter disturbance detectable on imaging given the greater safety protocols in place at the amateur level.  The study conducted  diffusion tensor imaging of the brains of 31 amateur boxers an compared these to a non boxing peer group.

The study found that “revealed widespread white matter disturbance partially related to the individual fighting history in amateur boxers. These findings closely resemble those in patients with accidental TBI and indicate similar histological changes in amateur boxers.

The full abstract is reproduced below –

Introduction

Professional boxing can lead to chronic traumatic encephalopathy, a variant of traumatic brain injury (TBI). Its occurrence in amateur boxers is a matter of debate since amateur boxing is considered to be less harmful due to more strict regulations. However, several studies using different methodological approaches have revealed subtle signs of TBI even in amateurs. Diffusion tensor imaging (DTI) is sensitive to microscopic white matter changes and has been proven useful in TBI when routine MR imaging often is unrevealing.

Methods

DTI, with tract-based spatial statistics (TBSS) together with neuropsychological examination of executive functions and memory, was used to investigate a collective of 31 male amateur boxers and 31 age-matched controls as well as a subgroup of 19 individuals, respectively, who were additionally matched for intellectual performance (IQ).

Results

All participants had normal findings in neurological examination and conventional MR. Amateur boxers did not show deficits in neuropsychological tests when their IQ was taken into account. Fractional anisotropy was significantly reduced, while diffusivity measures were increased along central white matter tracts in the boxers group. These changes were in part associated with the number of fights.

Conclusions

TBSS revealed widespread white matter disturbance partially related to the individual fighting history in amateur boxers. These findings closely resemble those in patients with accidental TBI and indicate similar histological changes in amateur boxers.

It is becoming ever clearer that mileage matters when it comes to exposure of head trauma and poor long term cognitive outcomes.

A recent study, titled  “Cognitive, Psychiatric, And Neuropathological Manifestations Of Repetitive Mild Traumatic Brain Injury” published as a dissertationn paper in Wayne State University’s Psychiatry and Behavioral Neurosciences sought answers to the important question of how much traumatic ‘mileage’ is too much when it comes to brain functioning.

In the study, which can be found here, the authors administered  30 head impacts over an extended period of time to lightly anesthetized, completely unrestrained mice in order to mimic sports related concussive and sub concussive impacts.  The authors then “assessed the sensorimotor, psychiatric, and cognitive outcomes of rmTBI at two different time points using different impact conditions“.

The study concluded that “Animals receiving repeated head impacts exhibited outcomes consistent with those observed in athletes with a history of rmTBI including depression-like behavior and cognitive impairment…Notably, these outcomes occurred in mice receiving head impacts that did not delay recovery of the righting reflex indicating that subconcussive impacts present just as serious risk of injury to the CNS as concussive blows. Aside from this outcome, these data indicate that there is a cumulative and dose-dependent effect of repetitive head impacts that exacerbate the neurobehavioral and neuropathological outcomes as seen in humans with a history of rmTBI.

The full abstract reads as follows –

Abstract

Millions of athletes participate in contact sports that involve repeated head impacts (e.g., football, ice hockey, boxing), often from a very young age, and it is feared that subsequent impacts can synergize with previous ones so that their effects on the brain become magnified. Repetitive mild traumatic brain injury (rmTBI) has been linked to the development of chronic traumatic encephalopathy (CTE). The neurodegeneration accompanying CTE occurs over many years following repeated head impacts and is characterized by progressive brain atrophy, accumulation of hyper-phosphorylated tau and aggregates of TDP-43, myelinated axonopathy, neuroinflammation and degeneration of white matter tracts. The relationship between head impact parameters (force, number, frequency) and the manifestations of rmTBI is not well understood nor is the severity or frequency of head injury required to trigger CTE. An animal model of rmTBI (i.e., sports-related TBI) is urgently needed to minimize risk of TBI in athletes and the studies described herein confirm that our method bears the attributes necessary to fulfill this need. The studies included in this project validate a method of rmTBI that unequivocally simulates human sports-related head impact in both form and outcome. To our knowledge, this is the first study to administer 30 head impacts over an extended period of time to a lightly anesthetized, completely unrestrained mouse. We have assessed the sensorimotor, psychiatric, and cognitive outcomes of rmTBI at two different time points using different impact conditions. Animals receiving repeated head impacts exhibited outcomes consistent with those observed in athletes with a history of rmTBI including depression-like behavior and cognitive impairment. The neuropathological outcomes of rmTBI included reactive gliosis, axonal degeneration, elevated levels of Aβ (1-42), β-amyloid, p-tau, TDP-43, and significant thinning of several white matter tracts. Notably, these outcomes occurred in mice receiving head impacts that did not delay recovery of the righting reflex indicating that subconcussive impacts present just as serious risk of injury to the CNS as concussive blows. Aside from this outcome, these data indicate that there is a cumulative and dose-dependent effect of repetitive head impacts that exacerbate the neurobehavioral and neuropathological outcomes as seen in humans with a history of rmTBI. This model will enable future study of the most pressing issues associated with sports-related head impact including the relationship between the number and frequency of head impacts to the development of behavioral and CTE-like outcomes. Future studies elucidating the cellular manifestations of rmTBI and its behavioral correlates will aid in the development of potential therapeutics. Finally, these results demonstrate the ability of our method to expand our understanding of the neuropathological, psychiatric, and cognitive sequelae underlying this insidious injury.

In my ongoing efforts to document scientific studies addressing safety issues in combat sports, a recent article was published examining the facial injury rate among boxing, wrestling and martial arts competitors.

The article, titled “Adding Insult to Injury – A National Analysis of Combat Sports-Related Facial Injury” was published this month in the Annals of Otology, Rhinology and Laryngology.  

The authors reviewed the National Electronic Injury Surveillance System (NEISS) for facial injuries from wrestling, boxing, and martial arts leading to emergency room visits from 2008 to 2013.  Perhaps somewhat counter-intuitively, the study found that wrestling, a combative sport without striking, led to the highest rate of facial injury requiring ER visits with an injury rate of 120 injuries per 100 000 participants with boxing and martial arts competitors suffering facial injuries at a rate of less than half of wrestlers.

The full abstract reads as follows:

Abstract

Objectives/Hypothesis: To estimate the incidence of patients presenting to emergency departments (EDs) for facial trauma sustained from participation in combat sports and evaluate injury patterns and patient demographics.

Methods: The National Electronic Injury Surveillance System (NEISS) was evaluated for facial injuries from wrestling, boxing, and martial arts leading to ED visits from 2008 to 2013. Relevant entries were examined for injury mechanism, location, type, as well as other patient characteristics.

Results: There were 1143 entries extrapolating to an estimated 42 395 ED visits from 2008 to 2013. Injury rates for boxing, marital arts, and wrestling were, respectively, 44, 56, and 120 injuries per 100 000 participants. Males comprised the majority (93.7%). A plurality of injuries involved lacerations (46.0%), followed by fractures (26.2%) and contusions/abrasions (19.3%). The proportion of fractures was highest among boxers (36.9%). Overall, the most common mechanisms of injury were punching, kicking, and head butting.

Conclusions: The significant number of ED visits resulted from combat sports facial trauma, reinforcing the importance of familiarity with injury patterns among practitioners managing facial trauma. As most injuries involve individuals younger than 19 despite guidelines suggesting children and adolescents avoid combat sports, these findings may be used for patient education and encouragement of the use of personal protective equipment. Furthermore, injury patterns reported in this analysis may serve as an adjunct for enhancing clinical history taking and physical examination.

In my ongoing efforts to document scientific studies addressing safety issues in combat sports, a useful article was published this month in the Korean Journal of Neurotrauma addressing sport related head injuries and return to sport protocols.

While the recent article titled A Review of Sport-Related Head Injuries, does not present any new data or findings, it is a well authored concise summary on the topic.

Of particular value for combat sports athletes, trainers and regulators are the comments on return to sport following concussion.

Given that CTE is linked to repeated concussive/sub-concussive blows, that concussion victims are 2-5.8 times more likely to experience a subsequent concussion and lastly that consequences from multiple concussions can be cumulative combat sports stakeholders should be well aware of if or when it is safe to return to sport following a concussive injury. The article provides the following sensible advice:

Athletes are not allowed to return to sports unless their symptoms have completely remitted. After full symptom resolution, they should return to sporting activities in a stepwise manner according to graduated return to play protocol (Table 2).12) Each step of the protocol requires 24 hours, and the process stops if there are any symptoms. Therefore, at least 1 week is required to return to sporting activities. In the final stage, the athlete undergoes a medical check-up before they are cleared to return to their sport. If any symptoms are observed, the athlete is ordered to rest and return to the previous stage of the protocol.

Neurotrauma Return To Combat Sports Following Concussion

 

Although the Amateur International Boxing Association’s recent ban of headgear in competition has been somewhat controversial, a recent study has found the ban has resulted in fewer head injuries for competitors.

The recent study, published in this month’s Clinical Journal of Sports Medicine, the authors reviewed “stoppages due to blows to the head by comparing World Series Boxing (WSB), without head guards, to other AIBA competitions with head guards” and further examined “the last 3 world championships: 2009 and 2011 (with head guards) and 2013 (without head guards).“.

The results showed “the number of stoppages due to head blows was significantly decreased without head guards. The studies also showed that there was a notable increase in cuts.

The study is titled “Use of Head Guards in AIBA Tournaments – A Cross Sectional Observational Study” and can be purchased here.

The full abstract reads as follows –

Objective: This study looks at the changes in injuries after the implementation of a new rule by the International Boxing Association (AIBA) to remove head guards from its competitions.

Design: A cross-sectional observational study performed prospectively. This brief report examines the removal of head guards in 2 different ways. The first was to examine the stoppages due to blows to the head by comparing World Series Boxing (WSB), without head guards, to other AIBA competitions with head guards. Secondly, we examined the last 3 world championships: 2009 and 2011 (with head guards) and 2013 (without head guards).

Setting: World Series Boxing and AIBA world championship boxing.

Participants: Boxers from WSB and AIBA world championships.

Interventions: The information was recorded by ringside medical physicians.

Main Outcome Measures: Stoppages per 10 000 rounds; stoppages per 1000 hours.

Results: Both studies show that the number of stoppages due to head blows was significantly decreased without head guards. The studies also showed that there was a notable increase in cuts.

Conclusions: Removing head guards may reduce the already small risk of acute brain injury in amateur boxing.

Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

Update April 29, 2016 – Today the NSAC provided me with the following details about the policy –

            Protecting the health and safety of all contestants is the most important goal of the Nevada Athletic Commission (NAC).  To effectuate that goal, across the last four years the NAC has been encouraging various fighters licensed by the NAC to participate in the Professional Fighter Brain Health Study being conducted by the Lou Ruvo Center for Brain Health at the Cleveland Clinic.  The researchers conducting that study have recommended, and the NAC has adopted as its policy, the development of a database containing neurological function assessment results on all fighters licensed in Nevada.  The information in that database will be gathered through implementation of a test called a C-3 Test, which makes various neurological assessments.

            In addition to the specific requirements described in NAC 467.027 which sets forth the minimum requirements for determining an applicants’ physical and mental fitness to engage in unarmed combat in the State of Nevada, the applicant must also take a C-3 Test to be administered by a representative of the Cleveland Clinic and submit the results of that test to the NAC.  The results of the C-3 Test must be submitted along with an unarmed combatant’s application for license similar to the presently required physician’s report, ophthalmologic eye examination, MRI/MRA, CBC, HIV and hepatitis test results.  This new testing is required every time that a fighter submits an application for a license.

            The C-3 Test is a neurological function assessment designed to gather information about a fighter’s balance, reaction times, hand-eye coordination and dynamic visual acuity.  The total time to take the C-3 Test is between 15-30 minutes.  Each applicant must present themselves to the Cleveland Clinic for testing prior to submitting their application for a license.  This test will be implemented officially in the upcoming months.

______________________________________

Athletic Commissions’ statutory reason for existing is the protection of the fighters they regulate.  To this end Athletic Commissions must stay current with issues involving brain trauma and evolve regulatory policies to keep pace with the science.  This is necessary not only to stave off potential litigation but more importantly to fulfill their mission statements of looking after the welfare of fighters.

Combative sports and permanent brain trauma are often a question of mileage.  This is a reality that at least one regulator, the Nevada State Athletic Commission, is acknowledging with evolving policies.

The NSAC has cooperated for years with the Cleveland Clinic’s Ruvo Center’s Professional Fighters Brain Health Study.  The study emphasizes early identification of neurocognitive decline and prediction of long-term neurological consequences for professional fighters.

This week the Nevada State Athletic Commission, influenced with information generated from the study, took steps in a positive direction announcing further diagnostic steps for fighters wishing to be licenced in the State.

In addition to current medical requirements, the NSAC will now require all fighters to undergo assessments using the Cleveland Clinic C3 application.  This tool, a mobile application used for assessing concussion symptoms, gives a baseline assessment of motor and cognitive function.  Repeat testing can then be done to measure functional decline following concussive or repeated sub-concussive trauma.  Regulators such as the NSAC can then use this data to help determine if a fighter is fit for ongoing licencing or if its time for the fighters to hang up the gloves.

The NSAC deserves credit for this proactive measure.  I have written the commission requesting a copy of the new policy.  I will update this article  with the wording of the policy once they respond.

 

Adding to this site’s summary of safety studies regarding combat sports, a recent literature review was published in this month’s Canadian Journal of Psychiatry addressing the link between adverse psychiatric consequences and adults who suffer concussions in sport.

In the article, titled “Knowing What We Don’t Know: Long-Term Psychiatric Outcomes following Adult Concussions in Sports” the authors reviewed 21 studies pertaining to depression, anxiety, substance use, and behavioural changes, including those highlighting chronic traumatic encephalopathy (CTE) searching for a link between sport concussion and these mental health outcomes.  The authors concluded that “There appears to be a growing body of evidence supporting the presence of long-term psychiatric and psychological sequelae following sport concussion in adults.”.

In an associated article the author notes “Specifically, in most studies, depressive symptoms were linked to concussion. The studies with regard to anxiety and also substance abuse were few, and findings were mixed with regard to a connection with concussion. Studies that focused on behavioural changes typically identified behaviour and/or cognitive changes after sports concussion, and a link was suggested in 2 studies. Chronic traumatic encephalopathy, a degenerative neurological disease that occurs years after concussion or repetitive head trauma, was included in this review. This broad syndrome is associated with mood, behavior, cognitive, and substance use problems. Clear subtypes and aetiologies have not yet emerged, but there is some evidence of symptom patterns of initial onset of cognitive problems followed by psychiatric complications or early psychiatric problems followed by cognitive decline“.

The full abstract is reproduced below –

Objective: Amidst a growing concern regarding concussion in sports, there is an emerging link between sport concussion and mental health outcomes. This review summarizes the current literature addressing long-term psychiatric sequelae associated with sport concussion in adults.

Method: Several databases were searched using a broad list of keywords for each ofconcussion, sports, and mental health, with a resultant 311 studies for initial review. After limiting studies based on duplication, appropriateness of data, and relevance, 21 studies remained pertaining to depression, anxiety, substance use, and behavioural changes, including those highlighting chronic traumatic encephalopathy (CTE).

Results: Most studies identified suggested an increased prevalence of depressive symptoms related to concussion history. A conference abstract and qualitative study suggested increasing anxiety related to concussion history; however, a PhD dissertation found no relationship. In reviewing substance use, several studies mentioned use in athletes suspected of having concussion histories, although no link was established, while another noted undiagnosed concussion as leading to current substance misuse. Regarding behavioural changes, all studies identified occurrences of behaviour and/or cognitive changes in participants, with 2 studies suggesting a link with concussion history. With respect to CTE, concerns with mood, behaviour, cognition, and substance use were consistently highlighted, suggesting relations to previous sport concussion; however, the notion of different CTE subtypes and clear aetiology behind concussion severity or frequency was not consistently elucidated.

Conclusion: There appears to be a growing body of evidence supporting the presence of long-term psychiatric and psychological sequelae following sport concussion in adults.

In my ongoing effort to document safety studies addressing combat sports, a recent study was published this month in the Saudi Journal of Sports Medicine seeking to find out the prevalence of injuries in national level boxers that occurred during the bout or training.

In the study, titled Prevalence of injuries in competitive boxers: A retrospective study, fifty-four national level male boxers were asked to report their injuries occurred in last 2 years, i.e., from August 2013 to July 2015. Only active competitive boxers were recruited.

The results indicated that the boxers suffered 7.59 injuries/year on an average while training or competing.  Head and facial injuries were the most frequent and 61% of the participants reported concussive injury in the two year span.

With respect to concussion rate the study noted as follows –

The common injury in head and face region was lip laceration. 81.48% of boxers had lip lacerations. Nasal bone contusion (61.12%), gingival bleeding (61.12%), and cerebral concussion (61.12%) are the second most common injuries in head and face region. In this study, head and face region is the most common site of injury which may be because of: Absence of head guard, different technique of training, the weight of the handcuff, and high-intensity stroke. Cerebral concussion may occur because of violent blow to the head, neck, or upper body which causes the brain to slide forcefully against the inner wall of the skull. Contusions usually occur on the skin as a result of trauma causing rupture of capillaries. Analysis of the database suggests that 10% of the total injuries were around the eye region