The American Journal of Sports Medicine http://ajs.sagepub.com/
Battle Scars Bruce Reider Am J Sports Med 2014 42: 1287 DOI: 10.1177/0363546514535717 The online version of this article can be found at: http://ajs.sagepub.com/content/42/6/1287
Published by: http://www.sagepublications.com
On behalf of: American Orthopaedic Society for Sports Medicine
Additional services and information for The American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - May 30, 2014 What is This?
Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
Editorial
Battle Scars MMA promoter in North America, agreed to a set of Unified Rules that was approved by the New Jersey Athletic Commission, leading to its current sanctioned status in almost all US states.10,11 Although these rules prohibit a number of ungentlemanly or unladylike behaviors such as biting, eye-gouging, using abusive language, or inserting a finger into any orifice or wound,14 they still leave the door open to a vast array of violent actions that fight fans crave. MMA fighters compete with a minimum of equipment: shorts, a mouth guard, a chest protector for women, a groin protector for men, and lightweight, fingerless gloves.13,14 The duration of fights is set at 3 to 5 rounds of 5 minutes each, but they are often terminated early by knockout (KO), submission of a combatant (‘‘tapping out’’), stoppage by a corner or attending physician, or technical knockout (TKO), which occurs when the referee judges that a fighter is unable to logically or safely defend him or herself.8,14 The medical implications of MMA were recently summarized in a systematic review published in our open-access affiliate, the Orthopaedic Journal of Sports Medicine.10 Combining the results of 5 studies into a meta-analysis, this review found that the composite injury rate was an impressive 229 (95% CI, 110-474) per 1000 athletic exposures. The portion of injuries sustained by the head was high, varying from 67% to a whopping 78%. Laceration (37%-59%), fracture (7%-43%), and concussion (4%-20%) were the most common injury types. The wide ranges in the injury statistics reflect considerable variability among studies in the methods of collecting data and defining injury, which was usually the purview of the ringside physician. A common weakness of these studies was a lack of detail in the documentation of injury severity. Not surprisingly, this review found that losing fighters sustained 3 times as many injuries as winners. In addition, bouts that ended in KOs or TKOs or fights that were settled by the judges’ decision were associated with injury rates more than twice that of bouts that ended with the submission of a combatant. Since fighters had a longer exposure to injury in bouts that went the distance, contests settled by judges’ decision actually had a lower injury rate than those ending in submission, when the injury rate was calculated by minutes of exposure. These findings seem to suggest that the risk of injury is lower when the fighters are more evenly matched. While the authors acknowledged that differences in methodology make it difficult to compare studies of diverse sports with confidence, the injury rate that they obtained was far above that reported for other popular combat sports such as judo, taekwondo, and amateur boxing, and placed MMA in competition with professional boxing for most injuries per 1000 athletic exposures. In any activity that features repeated blows to the head, the potential for concussion or other brain injury is always
And he carries the reminders Of ev’ry glove that laid him down. — ‘‘The Boxer’’; Words and Music by Paul Simon* Warrior, a 2011 film directed by Gavin O’Connor, is the fictional tale of Paddy Coughlin and his 2 estranged sons, set against a background of mixed martial arts (MMA) competition. Paddy is a recovering alcoholic approaching his 1000th day of sobriety, but his recent reformation cannot undo the damage that years of drunkenness have wrought upon his children. United only by their disdain for their father and their hatred of each other, the brothers present a striking outward contrast: Tommy, a hulking and brutal champion wrestler and ex-Marine; Brendan, a wiry high school physics teacher with a wife and 2 adorable daughters. Underneath, they are more nuanced and reminiscent of each other: Tommy is emotionally wounded and vulnerable, while Brendan vents his buried frustrations through amateur cage fighting. Unwittingly, the 2 young men have embarked on a violent collision course. Lured by extravagant prize money that they both desperately need, Tommy and Brendan punch and wheedle their separate ways into the Sparta MMA challenge. Staged amid the neon and glitz of the Atlantic City casinos, this self-styled ‘‘War on the Shore’’ will pit 16 leading middleweight MMA fighters against each other in a single-elimination tournament format. To gain the $5 million winner-take-all prize, a fighter must triumph in 4 punishing bouts in a single weekend. As the narrative builds to the inevitable final confrontation, Tommy and Brendan conquer their opponents in disparate fashion: Tommy by viciously pummeling his adversaries into unconsciousness within seconds, Brendan by enduring round after round of painful pounding and near-suffocation until finally trapping each unwary rival in a submission hold. Although Warrior is a work of fiction, MMA is a very real presence in the world of sport and entertainment. Introduced in North America in the early 1990s, MMA evokes the ancient Greek tradition of pankration, a competitive sport and combat technique that combined elements of boxing and wrestling.13 In its early incarnation, MMA created such a firestorm of criticism that it was banned in 40 US states, with politicians as prominent as Senator John McCain calling for its prohibition.3,10,11,13 Just when MMA appeared on the verge of extinction in the US, Ultimate Fighting Championship (UFC), the largest *Ó1968 Paul Simon (BMI). The American Journal of Sports Medicine, Vol. 42, No. 6 DOI: 10.1177/0363546514535717 Ó 2014 American Orthopaedic Society for Sports Medicine
1287 Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
1288 Editorial
The American Journal of Sports Medicine
a concern. In the MMA literature, the definition and analysis of concussion have varied greatly among individual reports.3,5,7,11,13,15 Sometimes only a knockout was accepted as evidence of concussion or ‘‘severe concussion,’’7,11,15 while at least 1 study did not classify KOs or TKOs as injuries at all.3 Without detailed information about the athletes’ neurocognitive status or pattern of recovery, conclusions about concussion rates have generally relied on inference,5 the recorded assessment of the ringside physician,3,6,11,15 or the recollections of individual fighters.13 In this issue of the American Journal of Sports Medicine, Hutchison and colleagues8 report the results of their extensive analysis of head trauma in professional MMA. This is a timely study, since a recent article has reported diffusion tensor imaging abnormalities suggestive of microscopic brain damage in boxers and MMA fighters.16 The authors painstakingly analyzed the publicly available scorecards and video recordings of 844 UFC MMA contests that ended in KO or TKO from 2006 to 2012. The scorecards reported the official outcomes of the bouts, while the complete fight videos, when obtainable, were analyzed using a scoring tool whose reliability had been previously documented.9 From the official scorecard outcomes, the authors determined that competitors 35 years or older had an increased risk of sustaining a KO or TKO, and each previous KO increased the risk of sustaining a subsequent KO (odds ratio = 1.30). The longer a fight lasted, the less likely it was to end in a KO or TKO, perhaps also suggesting that these outcomes were less likely among evenly matched fighters. Video analysis was restricted to 142 events for which digital recordings were publicly available. Scrutiny was focused on the 30 seconds prior to match stoppage caused by KOs, or by TKOs that resulted from repetitive strikes to the head. Of the 65 fighters who were KO’d, 41 sustained a second subsequent head impact, usually by striking the floor with their occiput. On average, KO’d competitors received about 5 to 6 head strikes in the 30 seconds before the knockout blow and an additional 2 or 3 head strikes between the KO-strike and match stoppage. Among 179 TKOs analyzed, 161 were judged to be the result of repetitive strikes, and videos were available for 77 of these. In the 30 seconds prior to match stoppage, the TKO’d fighter received an average of 17 head strikes, with a range of 5 to 46. Combining KOs and TKOs, the authors calculated an incidence of match-ending head trauma of 15.9 per 100 exposures, or 31.9% of matches. Without data from actual examinations of the fighters, the diagnostic implications of these findings remain somewhat speculative. Should all matches ending in head trauma be assumed to involve a concussion or other brain injury? Since only a minority of concussions result in unconsciousness, limiting the diagnosis of concussion to KOs would likely underestimate the incidence of such injuries. Although the authors acknowledge that they cannot confidently classify as concussions all TKOs following repetitive head strikes, a judgment by the referee that a fighter is unable to intelligently defend him or herself after repetitive head strikes is highly suggestive that some form of cognitive impairment was present.
Athletic competitions in which rendering one’s opponent unconscious is considered a highly desirable outcome have become repugnant to many physicians. Medical societies in Australia,2 Canada,6 the United Kingdom,17 and the United States1 have all called for a ban on MMA, although such position statements do not seem to have much effect on the spreading popularity of MMA competition. Perhaps more practically, Hutchison and colleagues propose possible interventions to mitigate the likelihood or the severity of head trauma, including better protective equipment, more rapid intervention by the referee following KOs and the introduction of a boxing-style ‘‘10-count’’ when a combatant is knocked to the floor by a head strike. Certainly, new studies based on more complete data than offered by ringside assessments and video analysis would also be desirable. One of the legendary heroes of the ancient Greek sport of pankration was Arrhichion, who died while successfully defending his title at the 54th Olympiad. Despite being caught in a choke-hold, Arrhichion refused to surrender. As he suffocated, the renowned pankratiast forced his opponent into submission by dislocating his ankle.4,12 Arrhichion’s corpse was honored as the Olympic champion. In Warrior, Paddy’s immersion in an audio recording of Moby Dick, the story of a man whose crazed obsession leads him and his followers down an inexorable path to self-destruction, runs through the narrative like a leitmotif and seems an apt metaphor for the fate of all 3 protagonists. Despondent over his inability to reconnect with his sons, Paddy nearly drinks himself to death, while Tommy and Brendan come close to killing each other in their climactic dual. Ultimately, they all survive, and their love for each other is rekindled by their near-death experience. Legendary heroes are often triumphant in death, and fictional characters are frequently healed and reborn through extreme hardship. Real people may also be transformed and ennobled by suffering, although few would voluntarily choose that route to self-improvement. By their heroic efforts, MMA fighters may gain both gold and glory. As medical professionals dedicated to the well-being of athletes, we are called upon to question the price of that glory.
Bruce Reider, MD Chicago, Illinois
REFERENCES 1. American Medical Association. H-470.965 ultimate and extreme fighting. Available at: https://ssl3.ama-assn.org/apps/ecomm/Policy FinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fhtml %2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-470.965.HTM. Accessed April 22, 2014.
Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
Vol. 42, No. 6, 2014
Battle Scars
2. Australian Medical Association. Mixed martial arts must be banned. Available at: http://www.amawa.com.au/mixed-martial-arts-mustbe-banned-ama-wa/. Accessed April 22, 2014. 3. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD, Li G. Incidence of injury in professional mixed martial arts competition. J Sports Sci Med. 2006;5:136-142. 4. Brophy RH 3rd. Deaths in the pan-Hellenic games: Arrachion and Creugas. Am J Phil. 1978;99(3):363-390. 5. Buse GJ. No holds barred sport fighting: a 10 year review of mixed martial arts competition. Br J Sports Med. 2006;40(2):169-172. 6. Canadian Medical Association. Mixed martial arts (MMA) ban. Available at: http://www.cma.ca/advocacy/infocapsule-mma. Accessed April 22, 2014. 7. Fields JC, Turner JL, Gebke K. Mixed martial arts injuries: an observational study. Clin J Sport Med. 2008;18(2):191. 8. Hutchison MG, Lawrence DW, Cusimano MD, Schweizer TA. Head trauma in mixed martial arts. Am J Sports Med. 2014;42(6):13521358. 9. Lawrence DW, Hutchison MG, Cusimano MD, Singh T, Li L. Interrater agreement of an observational tool to code knockouts and technical knockouts in mixed martial arts [published online ahead of print December 27, 2013]. Clin J Sport Med. doi: 10.1097/ JSM.0000000000000047.
1289
10. Lystad RP, Gregory K, Wilson J. The epidemiology of injuries in mixed martial arts: a systematic review and meta-analysis. Orthop J Sports Med. 2014; 2(1):2325967113518492. 11. Ngai KM, Levy F, Hsu EB. Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007. Br J Sports Med. 2008;42(8):686-689. 12. Philostratus the Elder, Arrichion, in Imagines Book 2, trans Arthur Fairbanks. Theoi E-Texts Library. http://www.theoi.com/Text/ PhilostratusElder2A.html#6 13. Rainey CE. Determining the prevalence and assessing the severity of injuries in mixed martial arts athletes. N Am J Sports Phys Ther. 2009;4(4):190-199. 14. Rules and Regulations. UFC. http://www.ufc.com/discover/sport/ rules-and-regulations#5. Accessed April 22, 2014. 15. Scoggin JF III, Brusovanik G, Pi M, et al. Assessment of injuries sustained in mixed martial arts competition. Am J Orthop. 2010;39(5):247-251. 16. Shin W, Mahmoud SY, Sakaie K, et al. Diffusion measures indicate fight exposure-related damage to cerebral white matter in boxers and mixed martial arts fighters. AJNR Am J Neuroradiol. 2014;35(2):285-290. 17. White C. Mixed martial arts and boxing should be banned, says BMA. BMJ. 2007;335(7618):469.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav
Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
Battle Scars Bruce Reider Am J Sports Med 2014 42: 1287 DOI: 10.1177/0363546514535717 The online version of this article can be found at: http://ajs.sagepub.com/content/42/6/1287
Published by: http://www.sagepublications.com
On behalf of: American Orthopaedic Society for Sports Medicine
Additional services and information for The American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - May 30, 2014 What is This?
Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
Editorial
Battle Scars MMA promoter in North America, agreed to a set of Unified Rules that was approved by the New Jersey Athletic Commission, leading to its current sanctioned status in almost all US states.10,11 Although these rules prohibit a number of ungentlemanly or unladylike behaviors such as biting, eye-gouging, using abusive language, or inserting a finger into any orifice or wound,14 they still leave the door open to a vast array of violent actions that fight fans crave. MMA fighters compete with a minimum of equipment: shorts, a mouth guard, a chest protector for women, a groin protector for men, and lightweight, fingerless gloves.13,14 The duration of fights is set at 3 to 5 rounds of 5 minutes each, but they are often terminated early by knockout (KO), submission of a combatant (‘‘tapping out’’), stoppage by a corner or attending physician, or technical knockout (TKO), which occurs when the referee judges that a fighter is unable to logically or safely defend him or herself.8,14 The medical implications of MMA were recently summarized in a systematic review published in our open-access affiliate, the Orthopaedic Journal of Sports Medicine.10 Combining the results of 5 studies into a meta-analysis, this review found that the composite injury rate was an impressive 229 (95% CI, 110-474) per 1000 athletic exposures. The portion of injuries sustained by the head was high, varying from 67% to a whopping 78%. Laceration (37%-59%), fracture (7%-43%), and concussion (4%-20%) were the most common injury types. The wide ranges in the injury statistics reflect considerable variability among studies in the methods of collecting data and defining injury, which was usually the purview of the ringside physician. A common weakness of these studies was a lack of detail in the documentation of injury severity. Not surprisingly, this review found that losing fighters sustained 3 times as many injuries as winners. In addition, bouts that ended in KOs or TKOs or fights that were settled by the judges’ decision were associated with injury rates more than twice that of bouts that ended with the submission of a combatant. Since fighters had a longer exposure to injury in bouts that went the distance, contests settled by judges’ decision actually had a lower injury rate than those ending in submission, when the injury rate was calculated by minutes of exposure. These findings seem to suggest that the risk of injury is lower when the fighters are more evenly matched. While the authors acknowledged that differences in methodology make it difficult to compare studies of diverse sports with confidence, the injury rate that they obtained was far above that reported for other popular combat sports such as judo, taekwondo, and amateur boxing, and placed MMA in competition with professional boxing for most injuries per 1000 athletic exposures. In any activity that features repeated blows to the head, the potential for concussion or other brain injury is always
And he carries the reminders Of ev’ry glove that laid him down. — ‘‘The Boxer’’; Words and Music by Paul Simon* Warrior, a 2011 film directed by Gavin O’Connor, is the fictional tale of Paddy Coughlin and his 2 estranged sons, set against a background of mixed martial arts (MMA) competition. Paddy is a recovering alcoholic approaching his 1000th day of sobriety, but his recent reformation cannot undo the damage that years of drunkenness have wrought upon his children. United only by their disdain for their father and their hatred of each other, the brothers present a striking outward contrast: Tommy, a hulking and brutal champion wrestler and ex-Marine; Brendan, a wiry high school physics teacher with a wife and 2 adorable daughters. Underneath, they are more nuanced and reminiscent of each other: Tommy is emotionally wounded and vulnerable, while Brendan vents his buried frustrations through amateur cage fighting. Unwittingly, the 2 young men have embarked on a violent collision course. Lured by extravagant prize money that they both desperately need, Tommy and Brendan punch and wheedle their separate ways into the Sparta MMA challenge. Staged amid the neon and glitz of the Atlantic City casinos, this self-styled ‘‘War on the Shore’’ will pit 16 leading middleweight MMA fighters against each other in a single-elimination tournament format. To gain the $5 million winner-take-all prize, a fighter must triumph in 4 punishing bouts in a single weekend. As the narrative builds to the inevitable final confrontation, Tommy and Brendan conquer their opponents in disparate fashion: Tommy by viciously pummeling his adversaries into unconsciousness within seconds, Brendan by enduring round after round of painful pounding and near-suffocation until finally trapping each unwary rival in a submission hold. Although Warrior is a work of fiction, MMA is a very real presence in the world of sport and entertainment. Introduced in North America in the early 1990s, MMA evokes the ancient Greek tradition of pankration, a competitive sport and combat technique that combined elements of boxing and wrestling.13 In its early incarnation, MMA created such a firestorm of criticism that it was banned in 40 US states, with politicians as prominent as Senator John McCain calling for its prohibition.3,10,11,13 Just when MMA appeared on the verge of extinction in the US, Ultimate Fighting Championship (UFC), the largest *Ó1968 Paul Simon (BMI). The American Journal of Sports Medicine, Vol. 42, No. 6 DOI: 10.1177/0363546514535717 Ó 2014 American Orthopaedic Society for Sports Medicine
1287 Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
1288 Editorial
The American Journal of Sports Medicine
a concern. In the MMA literature, the definition and analysis of concussion have varied greatly among individual reports.3,5,7,11,13,15 Sometimes only a knockout was accepted as evidence of concussion or ‘‘severe concussion,’’7,11,15 while at least 1 study did not classify KOs or TKOs as injuries at all.3 Without detailed information about the athletes’ neurocognitive status or pattern of recovery, conclusions about concussion rates have generally relied on inference,5 the recorded assessment of the ringside physician,3,6,11,15 or the recollections of individual fighters.13 In this issue of the American Journal of Sports Medicine, Hutchison and colleagues8 report the results of their extensive analysis of head trauma in professional MMA. This is a timely study, since a recent article has reported diffusion tensor imaging abnormalities suggestive of microscopic brain damage in boxers and MMA fighters.16 The authors painstakingly analyzed the publicly available scorecards and video recordings of 844 UFC MMA contests that ended in KO or TKO from 2006 to 2012. The scorecards reported the official outcomes of the bouts, while the complete fight videos, when obtainable, were analyzed using a scoring tool whose reliability had been previously documented.9 From the official scorecard outcomes, the authors determined that competitors 35 years or older had an increased risk of sustaining a KO or TKO, and each previous KO increased the risk of sustaining a subsequent KO (odds ratio = 1.30). The longer a fight lasted, the less likely it was to end in a KO or TKO, perhaps also suggesting that these outcomes were less likely among evenly matched fighters. Video analysis was restricted to 142 events for which digital recordings were publicly available. Scrutiny was focused on the 30 seconds prior to match stoppage caused by KOs, or by TKOs that resulted from repetitive strikes to the head. Of the 65 fighters who were KO’d, 41 sustained a second subsequent head impact, usually by striking the floor with their occiput. On average, KO’d competitors received about 5 to 6 head strikes in the 30 seconds before the knockout blow and an additional 2 or 3 head strikes between the KO-strike and match stoppage. Among 179 TKOs analyzed, 161 were judged to be the result of repetitive strikes, and videos were available for 77 of these. In the 30 seconds prior to match stoppage, the TKO’d fighter received an average of 17 head strikes, with a range of 5 to 46. Combining KOs and TKOs, the authors calculated an incidence of match-ending head trauma of 15.9 per 100 exposures, or 31.9% of matches. Without data from actual examinations of the fighters, the diagnostic implications of these findings remain somewhat speculative. Should all matches ending in head trauma be assumed to involve a concussion or other brain injury? Since only a minority of concussions result in unconsciousness, limiting the diagnosis of concussion to KOs would likely underestimate the incidence of such injuries. Although the authors acknowledge that they cannot confidently classify as concussions all TKOs following repetitive head strikes, a judgment by the referee that a fighter is unable to intelligently defend him or herself after repetitive head strikes is highly suggestive that some form of cognitive impairment was present.
Athletic competitions in which rendering one’s opponent unconscious is considered a highly desirable outcome have become repugnant to many physicians. Medical societies in Australia,2 Canada,6 the United Kingdom,17 and the United States1 have all called for a ban on MMA, although such position statements do not seem to have much effect on the spreading popularity of MMA competition. Perhaps more practically, Hutchison and colleagues propose possible interventions to mitigate the likelihood or the severity of head trauma, including better protective equipment, more rapid intervention by the referee following KOs and the introduction of a boxing-style ‘‘10-count’’ when a combatant is knocked to the floor by a head strike. Certainly, new studies based on more complete data than offered by ringside assessments and video analysis would also be desirable. One of the legendary heroes of the ancient Greek sport of pankration was Arrhichion, who died while successfully defending his title at the 54th Olympiad. Despite being caught in a choke-hold, Arrhichion refused to surrender. As he suffocated, the renowned pankratiast forced his opponent into submission by dislocating his ankle.4,12 Arrhichion’s corpse was honored as the Olympic champion. In Warrior, Paddy’s immersion in an audio recording of Moby Dick, the story of a man whose crazed obsession leads him and his followers down an inexorable path to self-destruction, runs through the narrative like a leitmotif and seems an apt metaphor for the fate of all 3 protagonists. Despondent over his inability to reconnect with his sons, Paddy nearly drinks himself to death, while Tommy and Brendan come close to killing each other in their climactic dual. Ultimately, they all survive, and their love for each other is rekindled by their near-death experience. Legendary heroes are often triumphant in death, and fictional characters are frequently healed and reborn through extreme hardship. Real people may also be transformed and ennobled by suffering, although few would voluntarily choose that route to self-improvement. By their heroic efforts, MMA fighters may gain both gold and glory. As medical professionals dedicated to the well-being of athletes, we are called upon to question the price of that glory.
Bruce Reider, MD Chicago, Illinois
REFERENCES 1. American Medical Association. H-470.965 ultimate and extreme fighting. Available at: https://ssl3.ama-assn.org/apps/ecomm/Policy FinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fhtml %2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-470.965.HTM. Accessed April 22, 2014.
Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
Vol. 42, No. 6, 2014
Battle Scars
2. Australian Medical Association. Mixed martial arts must be banned. Available at: http://www.amawa.com.au/mixed-martial-arts-mustbe-banned-ama-wa/. Accessed April 22, 2014. 3. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD, Li G. Incidence of injury in professional mixed martial arts competition. J Sports Sci Med. 2006;5:136-142. 4. Brophy RH 3rd. Deaths in the pan-Hellenic games: Arrachion and Creugas. Am J Phil. 1978;99(3):363-390. 5. Buse GJ. No holds barred sport fighting: a 10 year review of mixed martial arts competition. Br J Sports Med. 2006;40(2):169-172. 6. Canadian Medical Association. Mixed martial arts (MMA) ban. Available at: http://www.cma.ca/advocacy/infocapsule-mma. Accessed April 22, 2014. 7. Fields JC, Turner JL, Gebke K. Mixed martial arts injuries: an observational study. Clin J Sport Med. 2008;18(2):191. 8. Hutchison MG, Lawrence DW, Cusimano MD, Schweizer TA. Head trauma in mixed martial arts. Am J Sports Med. 2014;42(6):13521358. 9. Lawrence DW, Hutchison MG, Cusimano MD, Singh T, Li L. Interrater agreement of an observational tool to code knockouts and technical knockouts in mixed martial arts [published online ahead of print December 27, 2013]. Clin J Sport Med. doi: 10.1097/ JSM.0000000000000047.
1289
10. Lystad RP, Gregory K, Wilson J. The epidemiology of injuries in mixed martial arts: a systematic review and meta-analysis. Orthop J Sports Med. 2014; 2(1):2325967113518492. 11. Ngai KM, Levy F, Hsu EB. Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007. Br J Sports Med. 2008;42(8):686-689. 12. Philostratus the Elder, Arrichion, in Imagines Book 2, trans Arthur Fairbanks. Theoi E-Texts Library. http://www.theoi.com/Text/ PhilostratusElder2A.html#6 13. Rainey CE. Determining the prevalence and assessing the severity of injuries in mixed martial arts athletes. N Am J Sports Phys Ther. 2009;4(4):190-199. 14. Rules and Regulations. UFC. http://www.ufc.com/discover/sport/ rules-and-regulations#5. Accessed April 22, 2014. 15. Scoggin JF III, Brusovanik G, Pi M, et al. Assessment of injuries sustained in mixed martial arts competition. Am J Orthop. 2010;39(5):247-251. 16. Shin W, Mahmoud SY, Sakaie K, et al. Diffusion measures indicate fight exposure-related damage to cerebral white matter in boxers and mixed martial arts fighters. AJNR Am J Neuroradiol. 2014;35(2):285-290. 17. White C. Mixed martial arts and boxing should be banned, says BMA. BMJ. 2007;335(7618):469.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav
Downloaded from ajs.sagepub.com at UCSF LIBRARY & CKM on March 27, 2015
