Safety - the third part of the Kevin Lally MMA trilogy

Kevin Lally finishes up his wonderful MMA trilogy of blogs today with a quite 'sciencey' look at safety issues in MMA and comparisons to other sports. Here are the links to his first two MMA blogs:

Blog 1: https://sportyman2020.blogspot.com/2020/06/mixed-martial-arts-origins.html

Blog 2: https://sportyman2020.blogspot.com/2020/06/mma-in-ireland-tale-of-tragedy-and.html

And you can follow the polymathic Dr. Lally on Twitter @kevinly

So many thanks again Kevin and it's over to you...

MMA Safety

Deaths in MMA are rare and are less numerous than boxing deaths. While there are a much larger range of techniques used in MMA (punches, kicks, grappling techniques etc.) the number of significant head strikes landed during a bout per minute is less than that of professional boxing. However, boxing has two very different codes, professional and amateur. While the essential rules are the same, glove size, number of rounds and the threshold to end the fight due to trauma differ.

While the rule-set in Professional MMA has finally been agreed (https://www.ufc.com/unified-rules-mixed-martial-arts) what exactly constitutes amateur and what is professional or semi-professional is unclear. Is it merely the presence of payment? The expectations from the audience? Based on experience of the competitors? Bernard Dunne, an Irish former WBA Super Bantam weight champion reports he had over 100 amateur boxing bouts before his pro-boxing debut. It would be a struggle to find a professional MMA fighter with more than 10 amateur bouts. I could not find the amateur MMA record for either Charlie Ward or Joao Carvalho, the two fighters involved in the tragic circumstances resulting in Joao’s death but Joao had only been competing in the sport professionally for a year. 

Most Dangerous Sports?

It is difficult to track the exact incidence of death during sport. Some organisations only report deaths that occurring during a formal competition rather than in training or informal competition. This opinion piece in the BMJ alludes to some global death rates: (https://www.bmj.com/content/352/bmj.i389.full)

·         horseracing (128/100,000 participants a year),

·         parachuting (126)

·         mountaineering (51)

·         professional boxing (7.6)

·         motorcycle racing (7)

·         amateur boxing (1.39)

Unfortunately, MMA is not included here and how exactly the rates are calculated are not described. However, when it comes to mortality rates, we can see that high velocity and high impact sports are inherently the most dangerous. Horse racing, motorsport and downhill skiing are all associated with deadly injuries.

BASE (building, antenna, span, earth) jumping is an extreme sport which involves a person jumping from a height and gliding with aid of a parachute to the ground. There were 9 fatal injuries in a 10 year period from one particular jumping site in Norway (reported here https://pubmed.ncbi.nlm.nih.gov/17495709/)

 

Between Jan 1, 2000 and May 31, 2010 there were 42 confirmed deaths internationally  during Marathon competition running from myocardial infarction.

There have been 16 confirmed deaths resulting from MMA bouts since 2001 to now (a longer period). However, we must take into account there have been at least 2 million marathon runners in the period study so the proportion of deaths is much lower. The reference is Wikipedia https://en.wikipedia.org/wiki/Fatalities_in_mixed_martial_arts_contests. You could also look at it from the perspective of injury per unit time experiencing the sport, so a Marathon can go on for hours while an MMA fight might be over in 6 seconds.

Taking other injury into account, the relative risks of combat sports rise in comparison to other sports.

The incidence of injury is high in combat sports. However, it is worth distinguishing between significant head injury e.g. concussion and superficial or minor injuries like sprained toes.

From ‘The Epidemiology of Injuries in Mixed Martial Arts, A Systematic Review and Meta-analysis we can see that injuries in MMA are focused more on head and neck zones of the body with concussion accounting for many injuries.

Role of Intent

A frequent rebuttal to the above is that unlike boxing and MMA, the purpose of horseracing or marathon running is not to harm your competitor. This is a legitimate consideration that while other sports have much higher death rates there is no intent to harm. While the intent in combat sports is purely sporting the acts of hitting your opponent are intentional and deliberate.

Non-traumatic injuries

For sake of completion it is worth mentioning that some of the harms associated with MMA and boxing are secondary to weight-cutting practices. Weight cutting is distinct from focused weight loss. In focused weight loss an athlete may go through a strict diet and rigorous training regime to lose body and increase muscle mass over a period of weeks to months. Think Rocky Balboa and his raw eggs and brutal training montage. Weight cutting on the other hand is the sudden drop of water weight by rapid dehydration. Over a period of 2-72 hours an athlete will manipulate their body water content to drop their body weight to meet an entry criterion. They achieve this by many different methods including wearing sweat suits, using saunas and taking salt-baths. Wrestling, MMA, boxing and horse racing are common sports with strict weight classes. Once the weigh-in has been made the athletes do their best to replenish water and energy stores. Acute kidney injury and rhabdomyolysis (severe muscle breakdown) have been reported. There is a suggestion that weight cutting leads to a decrease in brain volume and an increase in brain injury following sporting contest however there is a confounder of dehydration leading to reduced cognitive performance skewing the results. https://pubmed.ncbi.nlm.nih.gov/17495709/

Regulation

We can safely acknowledge that MMA is not to everyone’s tastes. In a similar fashion, golf would not be to everyone’s taste but there are less calls for banning and prohibition. However, the risk associated with MMA, while comparable with professional boxing are substantial. From the point of view of individual autonomy, you must argue that competitors once adequately informed of the risk are entitled to participate. What’s left then for society to decide? Regulation?

While everyone agrees that sports like MMA must be made as safe as possible there is huge disagreement on exactly what changes must be made and which governing body will be empowered to regulate. The history of martial arts is rampant with corruption and stories of demise at the expense of bureaucracy. The absence of a robust evidence base for MMA safety is problematic. In the absence of this evidence base, most MMA organisations continue to draw from the experience of boxing to draft changes for MMA legislation.

A clearer distinction between amateur and professional MMA is desirable. Shorter fights, lower thresholds to stop for injury, protective equipment and fair match making will likely help. There will always be a place for prize fighting, but high stakes events must come with proportional rewards. A sensible national governing body that works under the auspices of Sport Ireland ran in democratic fashion will likely expedite improvements. The reality is MMA has become mainstream and attempts at prohibition will likely be counterproductive from a harm-reduction standpoint.

Regulation in Ireland

In many ways Ireland is ahead of the curve. The Irish Amateur Pankration Association was relabelled as the Irish MMA association with their own website http://mmaireland.ie/. Their stated goal is “to achieve National Governing Body status and recognition of MMA as a legitimate sport, suitable for all ages and levels of ability.”

They are affiliated with the international Federation of MMA  https://immaf.org/ with a view to regulating “elite amateur MMA”.

Safe MMA (https://safemma.org/about/ )is a medical charity  “set up for the public benefit of protecting the health and safety of mixed martial arts competitors in the UK & Ireland”. They have many recommendations and stipulations for competitors listed on their website, including regular MRI brain scans for professional fighters and once-off MRA brain scans to check for structural abnormalities.

Ultimately the sport of MMA is here to stay in both the context of a sporting hobby for amateurs and a potential career for professionals. Regulation will be required at all levels that is backed up by evidence-based sensible health and safety systems.