Send letter to journal:
Re: Re: Mixed martial arts not all bad

Dear Editor,

Having trained for, competed in, and served as ringside physician for numerous full-contact martial arts competitions, I took great interest in reading Dr. G.H. Bledsoe’s letter “Mixed martial arts not all bad.”[1] I appreciated his feedback regarding my article[2] and applaud his drive to research combat sports with utmost objectivity. Acknowledging the dangers of participation both from the perspective of a researcher and former fighter, I would like to address some of Dr. Bledsoe’s insights regarding mixed martial arts (MMA).

Dr. Bledsoe commented, “Sanctioning [of MMA] brought about many rule changes that mandated weight classes, time limits for rounds and matches, and eliminated many of the most dangerous techniques including stomps, head butts, and groin attacks.”[1] Unsanctioned until 2000, the United States-based MMA organisation (USMMAO) used in my study had already mandated rounds in 1995, weight classes in 1997, and “protective” MMA gloves shortly thereafter. Since its inception in 1997, the Japan-based MMA organisation (JMMAO) used in my study mirrored the same rules and regulations of the sanctioned USMMAO events. In addition, no matches in my study were stopped as the direct result of head butts (when legal) and 2 of the 642 matches (0.3%) were stopped due to stomps to the head. At the time this letter was released, head stomps remained a legal technique in the JMMAO despite sanctioning.

Dr. Bledsoe noted that MMA was sanctioned in September 2001. Although this referred to the first MMA event in Las Vegas approved by the Nevada State Athletic Commission, the New Jersey State Athletic Control Board was actually the first to sanction the sport in Atlantic City one year prior.

I compared match stoppages due to head impact in the USMMAO during 1993-1997 (MMA gloves not mandatory) to those during 1998-2003 (MMA gloves mandatory). Twenty-four of 120 matches (20.0%) were stopped due to head impact from 1993-1997, while 98 of 287 matches (34.1%) were stopped due to head impact from 1998-2003 (chi square analysis, p=0.01). Hence, mandatory wear of MMA gloves and subsequent sanctioning of USMMAO events were not associated with a reduction in match stoppages due to head impact. Sanctioned or not, the sport will remain inherently risky so long as the primary intent of the MMA encounter is to inflict trauma on one’s opponent.

Dr. Bledsoe stated, “The fact that MMA has no ‘standing eight count’ enabling a concussed participant time to recover and continue fighting is a tremendous step toward diminishing traumatic brain injury.”[1] The validity of this statement should be assessed via neuropsychological testing, neuroimaging, and/or neural biomarkers.[3,4] Since concussion (e.g., transient loss of consciousness following a blow to the head) does not reliably correspond to injury severity,[5] the MMA competitor that is removed from a match following concussion may receive no advantage in neuronal preservation over the boxer who continues fighting following a standing eight count. Independent of rules, blunt head trauma sustained among those who train and compete in MMA merits further research.

I look forward to reading the article by Dr. Bledsoe and colleagues,[6] as their work will serve to further elucidate those medical issues most salient to this burgeoning sport. I appreciate your objective consideration of the combat sports and, through our continued efforts, we will hopefully prevent undue morbidity and mortality.

Sincerely,

George J. Buse MD, CSCS

Department of Aerospace / Preventive Medicine, Cannon USAF Clinics, Cannon Air Force Base, New Mexico

References

1. Bledsoe GH. Mixed martial arts not all bad. Br J Sports Med, 9 Feb 2006, http://bjsm.bmjjournals.com/cgi/eletters/40/2/169 (accessed 15 Feb 06).

2. Buse GJ. No holds barred sport fighting: a 10 year review of mixed martial arts competition. Br J Sports Med 2006;40:169-72.

3. Erlanger DM, Kutner KC, Barth JT, et al. Neuropsychology of sports -related head injury: dementia pugilistica to post concussion syndrome. Clin Neuropsychol 1999;13:193-209.

4. Chen DQ, Zhu LL. Dynamic change of serum protein S100b and its clinical significance in patients with traumatic brain injury. Chin J Traumatol 2005;8:245-8.

5. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196-204.

6. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD, Li G. Incidence of injury in professional mixed martial arts competitions. The Journal of Sports Science and Medicine (in press).

Disclaimer: The views expressed herein are not to be construed as reflecting the policies of the United States Air Force or Department of Defense.

Send letter to journal:
Re: Mixed martial arts not all bad

Dear Editor,

I read with interest the article written by Dr. G.J. Buse entitled, No holds barred sport fighting: a 10 year review of mixed martial arts competition published in the 6 February 2006 edition of your journal. As a researcher focused on injury prevention, I have recently been part of a research group reviewing data from both mixed martial arts competitions and professional boxing and enjoyed reading the information presented by Dr. Buse.

In an article published in October 2005 in the Southern Medical Journal, our research group attempted to define the overall injury rate of athletes participating in professional boxing.[1] We reviewed data from the fight cards published by the Nevada State Athletic Commission and noted any injury comments recorded by the ringside physicians. Our research demonstrated an overall injury rate of 17.[1] injuries per 100 boxer-matches with 11.3% of those matches ending in knockout.

In an attempt to compare boxing injuries to mixed martial arts (MMA) injuries, we did a review of the fight cards for MMA matches using the same protocol as for the professional boxing matches. Our data—to be published soon by The Journal of Sports Science and Medicine—indicate that the overall injury rate for MMA matches is similar to professional boxing and the knockout rate is almost half that of professional boxing.[2]

In reviewing Dr. Buse’s data, I would have liked to have seen a comparison of injury rates before and after the sanctioning of the sport in September 2001. Though MMA began in the United States in 1993, these first fights only superficially resemble MMA matches today and were really very different competitions. Sanctioning brought about many rule changes that mandated weight classes, time limits for rounds and matches, and eliminated many of the most dangerous techniques including stomps, head butts, and groin attacks. Combining MMA matches prior to sanctioning with the sanctioned matches of today is confusing and is not helpful in attempting to determine the true injury risk for participants in these competitions.

It should also be noted that although there were five deaths in the boxing ring in the United States during 2005, there has never been an MMA death in the United States. The death cited by Dr. Buse occurred in an unregulated event during 1998 in the Ukraine.[3] MMA fighters in the United States now must pass all the prefight screening tests of professional boxers and are supervised by referees and ringside physicians. It is important not to lump MMA competitions with the infamous “Toughman” competitions—a “sport” that matches amateur participants against trained fighters using “one size fits all” protective gear and often supervised by chiropractors and other untrained medical staff—when comparing MMA to other combat sports. While MMA has never had a casualty in the United States, at least 12 deaths have resulted from Toughman competitions.[4]

MMA also has some rules that seem to be an improvement over professional boxing. The fact that MMA has no “standing eight count” enabling a concussed participant time to recover and continue fighting is a tremendous step toward diminishing traumatic brain injury. Furthermore, by allowing leg and arm attacks opponents have a more diverse target area and do not focus solely on attacking the head, and if in trouble, a participant can “tap out” to signify his desire to end the match. In our study, the “tap out” was the second most common means of ending a bout and ended approximately 30% of matches.2 Last, most MMA matches are far shorter than boxing matches. Sanctioned MMA events usually consist of three 5 minute rounds as compared to the usual ten to twelve rounds of boxing.

In sum, mixed martial arts competitions are a controversial subject in today’s sporting world and while no one would argue that these events are safe, it is important that we in the medical and research communities stay disciplined in our response to these subjects. I am thankful that your journal has taken an active role in seeking to determine the inherent risks of MMA competitions, and I hope that it will continue giving balanced and constructive suggestions regarding MMA and other such controversial subjects.

Sincerely,

Gregory H. Bledsoe MD, MPH
Assistant Professor
Department of Emergency Medicine
The Johns Hopkins University School of Medicine Baltimore, Maryland

References

1. Bledsoe GH, Li G, Levy, F. Injury risk in professional boxing. Southern Med J 2005; 98:994-998.

2. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD, Li G. Incidence of injury in professional mixed martial arts competitions. The Journal of Sports Science and Medicine (in press).

3. Porter K. Chipley man dies from injuries suffered in “ultimate fighting” match [news article online]. Panama City, FL: The News Herald, 1998, http://ap.emeraldcoast.com/nharchive/index.php (accessed 6 Feb 2006).

4. Branch, G. Toughman Competition Faces Its Own Battle. USA Today, 3C, 20 May 2003.