CTE – Braindisease’s Weblog

Ensuring and maintaining brain health of the combat sport athlete

Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.

Combat sports such as professional boxing and mixed martial arts (MMA) are popular sports with high risk for both acute and chronic traumatic brain injuries (TBI). Unfortunately, combatants have died in the ring or soon after the completion of a bout usually due to an acute catastrophic neurological event such as an acute subdural hematoma (SDH); which has been documented to be the most common cause of boxing related mortality. Acute TBI is just the tip of the iceberg when it comes to neurological injuries caused by combat sports. Hidden under the surface and away from the eyes of the public and media are the equally devastating chronic neurological sequelae of boxing and MMA including but not limited to chronic posttraumatic headache, chronic posttraumatic dizziness, posttraumatic cognitive impairment, posttraumatic Parkinsonism, posttraumatic dementia, dementia pugilistica, punch drunk syndrome, chronic traumatic encephalopathy (CTE) and neuropsychological sequelae such as mood, behavioral changes and depression.

At present there are no validated imaging or bio fluid (blood, cerebrospinal fluid) biomarkers for concussion and many of the above chronic neurological sequelae of boxing and MMA. In the absence of biomarkers; prognostication of the brain health of a combat sports athlete is inherently difficult. Most combatants undergo neuroimaging at the time of applying for initial licensure to compete in combat sports. This entails a magnetic resonance (MRI) scan of the brain without contrast usually carried out on a 1.5 or 3 Tesla strength magnet. In some countries and Commissions in the United States, a computed tomography (CT) scan of the head is acceptable in lieu of the MRI brain. While neuroimaging prior to licensure helps detect incidental clinically silent structural lesions with a high risk of bleeding such as aneurysm, arteriovenous malformation, large cavernoma, vein of Galen malformation and brain tumors, it does not yield any useful information about the function of the brain. Hence combining structural imaging with a functional study of the brain such as a formal neurocognitive evaluation should be considered at the time of initial licensure. Neurocognitive testing is a way to measure brain function non-invasively. It uses paper-and-pencil tests or computerized tests to assess important aspects of cognition such as attention, memory (immediate recall, short-term, long-term, auditory, visual), language, reaction time, perception and so on after factoring in the IQ and formal education of the examinee. A formal neurocognitive evaluation carried out by a qualified neuropsychologist is extremely helpful to formally assess the function of the brain as well as the mind and to grade/score it. The above test combo carried out at the time of the initial licensure serves as the baseline against which future test results are compared.

The average professional career of a combat sports athlete spans 10 years. During their active career most combatants fight on an average 2-6 times per year. It is recommended that a combat sports athlete undergo repeat MRI brain and neurocognitive evaluation after every 3 years. If the MRI shows evidence of prior TBI such as an area of encephalomalacia or gliosis, diffuse axonal injury, micro hemorrhages and the neurocognitive scores show a demonstrable decline, the combatant should be flagged. These combatants may need further tests such as PET scan of the brain, an electroencephalogram (EEG) and referral to a neurologist. On a case by case some may be allowed to proceed with their career under close observation while others may be counseled to hang up their gloves in order to prevent further and at times irreversible brain damage.

The brain is like a muscle and needs to be exercised, nourished and nurtured. The more it is exercised the stronger it becomes. Use it or lose it has scientific validity. Combat sports athletes should be counseled about brain health and how to build their cognitive reserve by doing exercises such as crossword puzzles, playing chess, reading, writing, listening to music or learning a new language or musical instrument. Supplements such as magnesium oxide and vitamin B12 are generally acknowledged to be brain healthy. A brain healthy Mediterranean diet which entails cooking food in extra virgin olive oil, less of dairy, less of red meat, more fish, more nuts should be promoted.

It is further recommended that the various sports commissions in the United States and abroad and combat sport’s governing bodies coordinate to assist with the setting up of an online central neuroimaging and neurocognitive database so that neuroimaging and neurocognitive data can be shared in the different countries where the combatant may compete.
The above interventions shall help to maintain the brain health of the combat sports athlete.

Reference

1. Sethi NK. Neuroimaging in contact sports: Determining brain fitness before and after a bout. SA J. Sports Med. 2017. vol.29 n.1 http://dx.doi.org/10.17159/2078-516x/2017/v29i0a2390

New data indicates the ever present danger of chronic traumatic encephalopathy (CTE) in contact sports such as boxing, mixed martial arts (MMA), football, ice-hockey and even soccer. Contrary to popular belief it is now felt that it is just not concussive injuries but even sub-concussive injuries which can predispose an athlete to CTE. This may be of importance to a soccer player who repeatedly heads the ball during play. There are other questions for which we still do not have a good answer.

1. How many concussions are needed and how severe they need to be for CTE to develop? Is there a limit beyond which the brain loses its capacity to compensate for chronic trauma and signs and symptoms of CTE appear? If so what is this limit? Can it be defined? If a player stops playing before this limit is reached would CTE be aborted?

2. Once CTE develops can it be reversed?

3. Is there a way to protect the brain from developing CTE apart from changing the way the games are played. Changing the rules of the game (such as avoiding head butts during football, heading the ball in soccer, direct blows to the head in MMA, wearing safety gear/helmets) shall certainly help but are there other neuroprotective strategies such as medicines (antioxidants, anti-inflammatory drugs) which can be given to prevent the onset and progression of CTE?

As you can see there are many questions for which we still lack good answers. Making the games we play safer certainly sounds a logical principle and hence the thrust to identify concussions in a timely fashion on the playing field and rest the player till complete recovery is documented. Neurologists, neurosurgeons and other physicians skilled in neurosciences by virtue of their training are better equipped to identify concussions and thus there is a growing call to have them by the side of the playing field in every professional and now even college level game. Biomakers and imaging markers to identify CTE in the living brain are also been explored.

Till more is known about CTE and more importantly on how to prevent and reverse it, making the games we love and play safer should be the goal.

Nitin K Sethi, MD

Tag: CTE

Ensuring and Maintaining Brain Health of the Combat Sports Athlete

Chronic traumatic encephalopathy-making the games we play safer