The American Journal of Sports

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Head Trauma in Mixed Martial Arts: Letter to the Editor

Marla Warner
Am J Sports Med 2014 42: NP43
DOI: 10.1177/0363546514539633
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competitions and should also have increased training

and/or ringside tests to perform on competitors. These
assessment tools will better help to decide whether competitors have suffered severe head trauma and should continue the match or not.
This topic is of great interest to me because my 9-yearold son just began taking jujitsu classes. His class includes
some Thai kickboxing as well. When he initially began his
classes, I was very concerned for his safety. I am thankful
that he enjoys the jujitsu (wrestling) style more so than the
boxing style. However, I am finding that chokeholds on the
neck, frequently performed in jujitsu, can be just as dangerous as blows to the head. There is an article to support
this entitled After Injury Leaves Him Paralyzed, an MMA
Fighter Battles Still in The Sacramento Bee.3 Devin
Johnson, an MMA competitor, was paralyzed by a chokehold performed on him during a match. This article discusses his story of injury through rehabilitation.
The article published in this journal relates to health
care because private health care insurance costs are currently so high that a traumatic injury sustained in MMA
could end up costing a significant amount of money over
the course of a lifetime. Repetitive injuries to the head
from MMA-style competition could lead to many expensive
magnetic resonance imaging (MRI) and/or computed
tomography scans over a period of time. If such severe
head trauma occurs, the competitor could even require
care for the rest of his or her life. This would lead to significant medical costs. Current government insurance may
not provide you with the best medical treatment because
of how the injury occurred. Insurance companies have
been creative in finding ways to eliminate subscribers
who might be costly.6(p1) This could be a huge problem
for competitors who are not willing to give up the sport.
If they are dropped from an insurance company, they
might have difficulty in finding another one to pick them
up. Then, they may also have trouble with coverage
because of having a pre-existing medical problem.
The King-Devick test (K-D test) is an evidence-based
practice that is being utilized ringside to determine if a contestant has suffered severe head trauma due to repetitive
blows to the head.2 This test is based on measurement of
the speed of rapid number naming, and it also recognizes
impairment 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 accurate
and reliable in identifying head trauma in MMA fighters.5 I
think that this is a good test to start providing more regularly not only at competitive matches but also at practices.
Dr Charles Burnick stated that there really is no objective way to decide when a person should stop fighting or
not be licensed to fight.5(p2) Some people say that mandatory MRI of all brain-injured competitors should be considered to avoid further head trauma.5 There is an estimated
average of 2 to 3 strikes to the head after a KO. Competitors would benefit from greater protection by referee intervention to avoid this.5 There is a definite urgency in
stopping competitive fights before severe head trauma
takes place. It is, however, a difficult job of the referees
to decide when an athlete is incompetent to continue

Head Trauma in Mixed Martial

Arts: Letter to the Editor
DOI: 10.1177/0363546514539633

Dear Editor:
A recent article in The American Journal of Sports Medicine entitled Head Trauma in Mixed Martial Arts, written by Michael G. Hutchison, David W. Lawrence, Michael
D. Cusimano, and Tom A. Schweizer,5 is about a critically
important topic that deserves our undivided attention.
Mixed martial arts (MMA) shows a recent increase in popularity and is a full combative sport with a high rate of
injuries, particularly head injuries.5 This sport is growing
tremendously in amateur and youth categories. There is
limited research on head trauma in MMA. I feel that it is
very important to research the mechanism and seriousness
of injuries related to the sport of MMA, particularly when
youth are involved. I think that it is more important to
begin taking greater measures to protect MMA competitors
from traumatic head injuries. Hutchison et al5 discuss the
incidence, risk factors, and characteristics of knockouts
(KOs) and technical knockouts (TKOs) due to repetitive
strikes in MMA. A KO is defined as occurring when a competitor is knocked down unconscious or disoriented, and
a TKO is defined when a referee stops the contest when
a competitor is disoriented to the point where he or she
is unable to defend himself or herself.5 What I am most
interested in is what is being done to prevent head trauma
in MMA. Mixed martial arts includes techniques from
a variety of sports including boxing, wrestling, karate,
taekwondo, jujitsu, Muay Thai, judo, and kickboxing. The
American Medical Association (AMA) describes MMA as
violent and dangerous and expresses its concerns about
the aggressiveness of the sport and it causing physical
harm, specifically brain injuries.5 A comparison was
made between match scorecards and digital video recordings of matches. Conclusions showed that rates of head
injuries in MMA are higher than those reported in boxing.
This is shocking to me! In a video analysis of 65 KOs, the
head 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%) sustained a secondary head impact with the fighting environment (ie, the floor, cage, or post).5(p4) Of these 41, 37
competitors (90.2%) struck the arena floor, most frequently
(n = 30, 73.2%) impacting the occipital region of the
head.5(p4) The specific region of the head that was struck
was the mandible (35 events [53.9%]), followed by the
maxillary (13 events [20.0%]) and temporal (13 events
[20.0%]) regions.5(p3) Public health officials and physicians
should be educating participants and patients appropriately about the risk of brain injuries associated with KOs
and TKOs from repetitive blows to the head.5 Physicians
and/or athletic trainers should be present especially at

The American Journal of Sports Medicine, Vol. 42, No. 7

2014 The Author(s)

NP43
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NP44 Letter to the Editor

The American Journal of Sports Medicine

fighting because of repetitive blows to the head. Keith

Kizer, executive director of the influential Nevada State
Athletic Commission, said medical research on MMA has
long been lacking, in part because doctors have typically
spurned the sport.4(p5) Kizer also recommended that
a national medical registry be available. However, this
would break HIPAA (Health Insurance Portability and
Accountability Act of 1996) laws, and it would be very
costly. Hutchison et al5 recommended that when fighters
appear disoriented, they should be given a count of 10 seconds, similar to boxing, to allow the referees time to evaluate if they feel that they can continue competing.
Hutchison et al5 also felt that a policy should be put into
place that athletes must undergo a complete medical examination after a KO or TKO before returning to training.
Both articles agree that further research is required to
reduce head trauma in MMA.
I would like to see physicians and public health figures
educate patients and participants in MMA more in depth
about the risk factors of severe head trauma. Referees
should also be required to have additional training in recognizing earlier when a competitor suffers a concussion. It
may cost MMA-related organizations more money to educate and perform increased precaution techniques for the
safety of competitors; however, they could avoid possible
lawsuits and high insurance costs later after a traumatic
head injury has occurred because these efforts were not
put into place. I feel that it would benefit MMA competitors
to have trained physicians and/or athletic trainers ringside, who understand the mechanism of head trauma and
know how to perform the K-D test. I truly feel that this
would prevent further and more severe head trauma in
the future. I personally would like to see greater

preventative steps taken, because of my sons love of the

sport of MMA, to avoid head trauma in MMA.
Marla Warner
Utica, New York, USA
Address
correspondence
to
Marla
Warner
(e-mail:
mwarner@svcsd.org).
The author declared that she has no conflicts of interest in the
authorship 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-inthe-news/2011/08/01/injuries-in-emerging-sports-calls-for-improvedmedical-understanding. Accessed April 6, 2014.
2. Galetta KM, Barrett J, Allen M, et al. The King-Devick test as a determinant 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-learnmore-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.

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