From the Olympic Games to Mixed Martial Arts: What Are the Medical Risks With Combative Sports - PowerPoint PPT Presentation

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From the Olympic Games to Mixed Martial Arts: What Are the Medical Risks With Combative Sports

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    1. From the Olympic Games to Mixed Martial Arts: What Are the Medical Risks With Combative Sports? Randall R Wroble MD FACSM Sportsmedicine Grant Columbus OH

    2. Understanding epidemiology is crucial in establishing risk factors and developing strategies for injury prevention

    3. Outline General considerations Sport-specific observations Thematic issues

    4. Key Messages Injury rates are high but comparable to other contact sports Uniquely wide variety of injuries and issues More research is needed to design effective prevention strategies

    5. General Considerations

    6. The Sports - Styles Striking-based Boxing Karate more hand techniques Kickboxing Taekwondo more kicking techniques Wushu Grappling-based Judo Wrestling Mixed - MMA Weapons-based - kendo

    7. The Sports - Participation Estimated 6.9 million adults and children in US alone Estimated 75 million participants worldwide 30-40% female Olympics boxing, judo, taekwondo, wrestling

    8. Limitations of Current Research Epidemiologic work is scarce if not unavailable for the majority of disciplines Inconsistencies in Injury definition Data collection and methods Study design Most studies are case series tournaments

    9. Limitations of Current Research Even within the individual sports, rules vary Type of contact Zone of contact Padding/protective equipment

    10. Limitations of Current Research Data especially lacking in females and children All of these adversely affect validity of available data Risk factors thus not well-delineated

    11. General Epidemiological Statements Across All Sports Exposure is similar Time in practice >> time in competition Injury incidence: practice > competition Injury rate: competition >> practice

    12. General Epidemiological Statements Across All Sports Most injuries are mild contusion, lacerations, sprains and incur little or no time loss Defender hurt more often than attacker Head injuries are greatest concern Lower extremity injury rates higher in taekwondo, wushu, kickboxing More injuries occur without protective equipment Sparring/fighting is most common setting

    13. Overall Injury Rates (Injuries/100 Participants) Boxing 21-42 Judo 13-24 Karate 34-38 Taekwondo 6-20 Wrestling (HS) 23-50 Wrestling (College) 19-288

    14. Sport-specific Observations

    15. Boxing Overall rate 171-250/1000 AE (Zazryn, Bledsoe) Amateur and female injury rates lower than in male professionals Most common epistaxis and lacerations

    16. Sport-specific Considerations - Boxing Acute head injuries 27-93% of reported injuries KO and TKO rate has decreased in Olympics 24% in 1988 1.5% in 2004 Chronic brain injury Eye retinal detachment Boxers knuckle chronic synovitis of 2nd or 3rd MCP joints Subluxation of extensor tendons due to sagittal band damage May require surgical repair

    17. Judo Injury rates 123/1000 AE (Barrault) Sport-specific considerations Throws upper extremity injuries 28-37% of injuries in kids (Pieter) 39-47% of injuries in adults (Pieter) Choke holds case reports of stroke

    18. Karate Injury rate 53/100 participants (McLatchie) Protective equipment gloves, mouthguards, shin and foot pads

    19. Sport-specific Considerations - Karate Injuries most common to head/neck/face 51-90% of injuries in kids (Pieter) Concussion 1.6/1000 AE (Stricevic) 0.9-5.4% of all injuries Hand techniques (punching)result in more upper extremity injuries 72% from punches 14% from kicks

    20. Kickboxing Injury rate 110 injuries/1000 AE (Zazryn) Protective equipment Varies by style and level but in general includes gloves, mouthguards, and groin protectors

    21. Kickboxing Concussions Pro - 17% of injuries 19.2/1000 AE (Zazryn) Amateur 62% of all injuries Shin injuries 23% of injuries, less when shin guards used

    22. MMA Fighters most commonly come from wrestling, kickboxing, or jujitsu background

    23. MMA Major changes in rules - weight classes, rounds, time limits, equipment Outlawed head butting, hair pulling, pinching, eye gouging, etc Match end 35% submission Tap out 34% TKO 24% decision 3% KO comparable to taekwondo, but lower than boxing or kickboxing 2% physician stopped fight

    24. Submission Holds Most common elbow lock

    25. MMA Injury rates similar to other disciplines Overall 236/1000 AE Concussion 15.4 48.3/1000 AE (Ngai, Buse) Protective equipment mouth guard, groin protector, gloves thinly padded with palm and fingers free

    26. Taekwondo Injury rate 21-168/1000 AE (Pieter) Protective equipment Headgear required

    27. Sport-specific Considerations - Taekwondo Concussion 7.3/1000 AE (Zemper) 4.3-7.5% of all injuries Newer rules - more points for head blows Appears to have resulted in more concussions Kicking techniques result in more lower extremity injuries 37-65% of injuries in kids (Pieter) 8-69% of injuries in adults (Pieter)

    28. Wrestling Styles Freestyle Greco-Roman American folkstyle HS and College Match length differs by style and level

    29. Wrestling Injury rates HS 23-50 injuries/100 wrestlers Higher in college Lower in youth wrestling Very limited international data Injuries to knee most common Unique patterns Skin infections Cauliflower ear

    30. Combative Sports Issues Making weight Acute and chronic head injury Blood borne infection Auricular hematoma Skin infection Eye injury Musculoskeletal injuries

    31. Making Weight

    32. Making Weight Weight matching Creates equity Reduces injury risk Allows broad size range of competitors Weight cutting occurs to gain advantage in power and strength

    33. Making Weight Weigh-in protocol varies considerably by style and level Weight control programs - 1998 HS and college require weight certification Based on body composition Euhydrated body fat minimums 5% college male, 7% HS male 12-14% female Max wt loss of 1.5%/wk International (FILA) wrestling and other combat sports do not regulate weight loss

    34. Making Weight Prevalence data limited primarily to wrestling College wrestling positive effect of rule changes Steen (1990) 87% of college wrestlers lost 5 kg weekly 15 times during a season Oppliger et al (2003) average weekly wt loss 2.9kg HS wrestling rule changes had smaller effect 70% of wrestlers cutting weight No data on female athletes Judo 70-80% reduce weight

    35. Making Weight - Methods Recommended techniques Slow, log-term weight reduction Modest short term dehydration High volume exercise Nutritional education Not recommended/illegal Severe dehydration Fasting Sauna, plastic/rubber suits Laxatives, diuretics

    36. Making Weight - Physiologic Effects Dehydration impairs cardiovascular and thermoregulatory function Heat illness 3 college wrestlers deaths in 1998 Short duration, high intensity activity less affected Lose lean mass not just fat Immune function?

    37. Making Weight - Performance Effects Does weight loss increase chance of success? Debate not settled Study results mixed College Horswill no HS Wroble yes Adolescents Alderman - yes

    38. Acute and Chronic Head Injury

    39. Acute Brain Injury Occur more in boxing than in any other sport Similar but lower rates in all other full contact disciplines Repeated deliberate blows to head Punches, kicks Deaths due to subdural hematoma Boxing - 659 reported 1915-1996

    40. Concussion Rates Pro boxers - 16-70% of all injuries (Zazryn) Amateur boxers - 6.5-52% of all injuries (Zazryn) Karate - 0.9-5.4% of all injuries Taekwondo 4.3-7.5% of all injuries Kickboxing 62.5% of all injuries Martial arts 25% of all competition injuries (Roh, Pieter) 63% of all injuries in 18 yr questionnaire study (Birrer)

    41. Adult Concussion Rates/100 Participants Boxing 14.0-44.7 Karate 0.4-2.8 Taekwondo 0.2-5.2

    42. Chronic Brain Injury Chronic traumatic encephalopathy Incidence data limited Amateur < pro Most are case reports Est. 9-25% in pro boxers Roberts 17% ex-boxers have CNS SX Only one case report in combat sports outside of boxing

    43. Chronic Traumatic Encephalopathy Mechanism numerous subconcussive and/or concussive blows to head Diagnosis difficult Delayed onset Would have developed anyway Confounding variables EtOH, drug use Other head trauma

    44. Chronic Traumatic Encephalopathy Symptoms variable Motor impairment Balance, coordination, parkinsonism Cognitive impairment Attention, memory One third of cases progressive Dose-response curve is unknown

    45. Chronic Traumatic Encephalopathy - Risk Factors Increasing age Amateur < pro Shorter bouts Headgear More padded gloves Mandatory suspension after head injury

    46. Chronic Traumatic Encephalopathy - Risk Factors Increasing exposure Number of bouts (>150) Career > 10 yrs Less exposure now so incidence likely will decrease Career length shorter Mean career length 19 to 5 yrs Bout number less: mean 336 to 13 Apolipoprotein E4 genotype

    47. Chronic Traumatic Encephalopathy - Prevention Glove weight heavier more padded gloves Headgear, mouthguards Better instruction and training coaches, refs, players Rule changes to reduce head blows Limiting exposure

    48. Chronic Traumatic Encephalopathy - Prevention Surveillance and supervision more detailed neurologic evaluation Annual medical checks Pre-bout screening CT or MRI Neuropsychological testing Identify high risk fighters

    49. Blood Borne Infection

    50. Blood Borne Infection - Transmission High risk sports Boxing, wrestling, MMA Bleeding wounds no cases reported of HIV transmission Doping & drug abuse Travel in endemic areas

    51. Blood Borne Infection Hepatitis, HIV 50-100x more risk of transmitting HBV HIV susceptible to disinfectants and drying HBV resistant to drying, simple detergents and alcohol and is stable on environmental surfaces, concentration in blood higher Outbreak in Sumo club 5/10 athletes

    52. Blood Borne Infection - Prevention Universal blood precautions Proper protective equipment mouthguards, headgear Vaccination for HBV safe, 95% effective Recommended for children and high risk athletes

    53. Blood Borne Infection - Testing Widespread mandatory screening generally not recommended Voluntary testing recommended for high risk athletes USA Boxing & USA Wrestling known infected athletes barred from competition Pro boxing most states require negative tests

    54. Control of Bleeding Amateur boxing no medication allowed Pro boxing any topical substance is allowed Time limits Boxing 1 minute between rounds HS wrestling 5 minutes cumulative International wrestling 2 minutes Judo disqualified after 3rd attempt Methods The Cutman Vaseline Avitene, Gelfoam, surgicel

    55. Auricular Hematoma

    56. Auricular Hematoma Wrestling 1.7-23.4% of all injuries Direct trauma or abrasion Head or knee Incidence reduced with headgear 51 to 35% Only 5% of coaches require headgear at practice Amateur boxing extremely rare with headgear

    57. Skin Infection

    58. Skin Infection Incidence 6-26% of reported injuries in wrestling Multiple reported outbreaks Risk factors Sweating, abrasions, close physical contact

    59. Skin Infection Problems Lack of awareness/dermatologic knowledge Doctor shopping Medical issues Severe - limb or life threatening Complications e.g. Herpes keratitis Cost of treatment

    60. Skin Infection - Bacterial Impetigo more common in HS wrestlers CA-MRSA Cellulitis Folliculitis Furunculosis

    61. Skin Infection - Fungal Tinea corporis 70% of HS wrestling skin infections 35-40% prevalence in judo athletes Duration of treatment in dispute

    62. Skin Infection - Viral Herpes gladiatorum HSV-1 Transmission risk 30% Up to 30% asymptomatic carriers Reported incidence higher in college than HS

    63. Skin Infection - Prevention Skin checks Barrier creams Hygiene Prophylaxis Tinea and herpes

    64. Eye Injury

    65. Eye Injury Studies limited except in boxing Retinal detachment, hyphema, cataracts 58% of boxers have vision-threatening injuries (Giovinazzo) 18% of wrestling injuries in one study but 90% were periorbital lacerations and corneal abrasions

    66. Eye Injury - Preventive Measures Mandatory eye exam at regular intervals Amateur boxing retinal tear or detachment disqualifies Improved documentation and record keeping Training ringside physicians Thumbless gloves?

    67. Musculoskeletal Injuries - Knee Injuries in Wrestling Lateral meniscus tear Other contact sports, incidence of meniscal tears Medial 4x lateral In wrestling Medial = lateral Cruciate ligaments tears uncommon

    68. Musculoskeletal Injuries - Knee Injuries in Wrestling Prepatellar bursitis Rarely reported in other sports 21% of all knee injuries Often recurrent Occasionally septic Deceiving presentation

    69. Key Messages

    70. Injury Rates Are High Comparable to other contact sports Studies limited, results highly variable Medical coverage vital Teaching opportunity

    71. Unique Variety of Issues Expertise required beyond musculoskeletal system Sport-specific knowledge base Incredible crucible of clinical material

    72. More and Better Research Is Needed to Design Effective Prevention Strategies Prevention strategies have proven effective but are limited in scope at present Wrestling weight loss rules Boxing oversight

    73. Examine each sport individually Standardization of injury definition Extend study population across age, competition level, weight, and gender Define safe level of exposure Examine training injuries Further identification of risk factors Protective equipment effectiveness & lifespan

    74. But most of all get involved!

    75. Thank You

    76. Starting Points for Prevention Strategies

    77. The Athlete Proper training Technique Hygiene Limits on weight reduction Size/ability matching

    78. The Sport Standardization and enforcement of rules Re-evaluate rules allowing blows to head Adequate supervision Coaching & officials education injuries and prevention Protective equipment Headgear Mouthguard Ear guards Sparring gloves Shin pads Chest/groin protector

    79. Environment Removal/padding of hazards Adequate space Appropriate temperature/humidity Quality mats Mat disinfection

    80. Health Support System PPE Medical coverage ambulance at boxing matches Injury tracking Emergency protocols Precise treatment protocols Proper rehabilitation Strict RTP criteria