It is known that as fighters absorb repeated blows to the head the size and circuitry of their brains are altered. What is not necessarily known is how best to interpret those changes, and if they cause brain diseases like Alzheimer’s and dementia.
A definitive step in that direction was taken last year, when the Lou Ruvo Center for Brain Health in Las Vegas launched a study of nearly 200 mixed martial artists and boxers. The center offers free MRI scans and required tests to fighters licensed in Nevada. In exchange, participants agreed to undergo a battery of cognitive tests and allow access to their brain scans over a period of at least four years. More than 180 active fighters have thus far signed on, divided about evenly between boxers and mixed martial artists.
Their brain scans will be studied to detect subtle changes in brain health that correlate with impaired thinking and functioning. If changes can be detected and interpreted early, there may be a way to reverse or soften trauma-induced brain diseases, like Chronic Traumatic Encephalopathy. The study could also point regulators to specific markers in fighters’ brain scans that indicate a problem.
“These athletic commissions are having to make decisions, in some sense arbitrarily, on whether a fighter can continue their career; they don’t have any objective markers to help them,” said Dr. Charles Bernick, who heads the study. “I think it’s fair to everybody in the sport if there were actually objective measures that can tell someone whether they should continue on or not.”
Bernick recently joined Jack Encarnacao on the Sherdog Radio Network “Rewind” program to discuss the study, the promise it holds and whether there is any scientific basis for long-held assumptions about the effects of fighting on combat athletes’ brains.
To stay updated on the show, follow it on Twitter @SherdogRewind.
Sherdog.com: Tell us where the study is at and what exactly it seeks to determine.
Bernick: This is officially titled the “Professional Fighters Brain Health Study,” so this is looking, as a group, at both mixed martial arts athletes and boxers, and there are several aims of this study. One is to be able to determine or identify the earliest changes of damage in the brain by using some of the newer techniques we have available with MRI scans, as well as other potential markers of injury. This could be chemicals in the blood or even changes in speech patterns and so on. The second is really to be able to determine which individual may be on their way to developing these long-term complications of repetitive head trauma. The most common one we hear about is Chronic Traumatic Encephalopathy, which of course has been in the news with the tragedy of [deceased NFL player and suicide victim] Junior Seau. And then the third is to find out why some people develop this chronic brain condition and others don’t, even with the same exposure, and whether that’s due to genetics or environmental factors or whatever. So those are the three overarching aims of the project. We started this about a year ago. We have now about 180-plus fighters that have participated in this study, and what the study involves is looking at these participants once a year for at least four years. We’d like to keep it going longer, but if we can get four years of information out of a substantial number of individuals, we’ll have learned a tremendous amount about a subject that we know very little about. We feel that the damage and the changes in these conditions start when people are actively fighting, and that’s where we have to look first if we’re going to detect these earliest changes.
Sherdog.com: How do you recruit fighters into participating?
Bernick: We in some sense have a carrot. In Nevada and many states, there is a requirement to have an MRI scan as part of licensure. So because in this study individuals get an MRI scan once a year, they get this potential $1,000 test for free. So we know that a lot of the fighters come in basically to save money, and we also offer some of the blood tests that they require for licensure: the HIV, Hepatitis B, Hepatitis C. That brings in some fighters. But the hope is that once they understand the importance of it and the value to their own lives, they’ll stick with it. We receive a variety of responses. Some people come in, again, just for the free tests. But some people do care, and they want to know, particularly if they’re later in their career. We have tremendous support from our Nevada Athletic Commission, which has really been helpful to us, and, of course, the UFC has been a tremendous supporter. So we have the backing of the industry in some sense, and, unlike other sports, they’ve been with us right from the start and they’ve supported this type of research. When we see athletes here, I think they all know, or most of them understand there is a risk of being in a sport where you may sustain repetitive concussions or sub-concussive injuries. For many of them, it’s a livelihood. They’ve been in this sport a long time. It’s a challenge. They love it. And I think what we’re trying to do is not discourage people from participating [in boxing and MMA] but somehow make it safer, make the sport safer.
Sherdog.com: Could this be a situation where you’ll be able to put solid science in front of a fighter that proves he has reached the point of no return and is risking serious mental health complications if he continues to fight?
Bernick: I think it will go two ways. I think the hope is, yeah, having objective information that we can present to the athletes so they can decide. So that’s, of course, the most important part. And, by the way, it doesn’t have to be all or none. We might find that there’s a certain frequency of fighting or density of fighting that becomes too dangerous at a certain point. So it may be that instead of saying, “You can’t fight at all” or “You should stop completely,” it may be that, well, you’re limited to fighting only twice a year and then training a certain amount before those fights. So we’ll have to see how this pans out. But, of course, aside from the individual fighter, as you might imagine, regulatory agencies would like this information, too, because these athletic commissions are having to make decisions, in some sense, arbitrarily on whether a fighter can continue their career, because they don’t have any objective markers to help them. And I think it’s fair to everybody in the sport if there were actually objective measures that can tell someone whether they should continue on or not, or, as I say, can fight a lesser amount. Or perhaps at some point we’ll have treatments, treatments that you can actually institute even before significant damage occurs.
Sherdog.com: When it comes to commissions making judgments about a fighter’s brain health, what makes it arbitrary? What don’t commissions have access to in making these decisions?
Bernick: I think at this point … we have no objective findings. That’s the problem, I think, at the moment. I mean, unless somebody has an obvious structural problem in the brain that we know threatens their health. Short of that, there is no objective measures for commissions to make decisions. So what do they do? They look, at least with boxers, (at) how they’ve been doing the last few fights. Are they starting to really lose their abilities? Are they getting knocked out earlier? And so on. So a lot of it is just kind of, again, intuitive, based on not tremendously objective measures, and we don’t have objective measures now. But the hope from a project such as ours and maybe others like it is that we’ll be able to say, “Alright, if you have such and such a change on your MRI scan between your last year and this year, then some disease is starting. You’re in trouble, and you better stop.”
Sherdog.com: Give us an idea of the type of change in a fighter’s brain that might be a sign of trouble.
Bernick: There’s a number of changes that we can actually measure on just a garden-variety MRI scan. One is we can measure the volume or size of certain areas of the brain, and, of course, if there is damage to that area, it will shrink in size. So we can measure that shrinkage, and, again, if the rate of shrinkage exceeds what you really would expect, that might be a dangerous sign. Or another common technique that’s readily available is looking at the fibers that course across the brain. We can actually visualize those and we can see what percentage of them are damaged. For example, maybe if there’s an increase in the percentage that’s damaged, that may be a sign. Or we’re now able to measure the connections between different areas of the brain and [if those get] disrupted a certain amount, then that might be a sign. So it is looking like there may be distinct markers on imaging of the brain that can give us, really, information on if a disease is starting, if Chronic Traumatic Encephalopathy is starting. A new technique that’s not available, but it’s being developed, is actually to be able to image tau (a protein in the brain that is connected to Alzheimer’s and dementia). This would be crucial. I mean, if we could actually measure it in individuals through scanning the brain, we would in some sense be able to identify the disease at its earliest stage. These things are not that far off, and, hopefully, within the next five years, 10 years, we’ll have these very objective markers.
Sherdog.com: Explain, if you could, the tau protein.
Bernick: Tau protein is a normal protein. What it really is involved in normally is the scaffolding or the skeleton of the brain cell, so it keeps the form of it intact. It turns out when tau changes its form that scaffolding just collapses, and then the cell gets damaged and machinery gets damaged. So we think tau is a marker of damage to the cell, and it’s really interesting; it’s now been shown that tau can move from one cell to another. Because one of the perplexities is, well, if you stop fighting, why should a disease progress? And it may progress because once you have that tau there, it actually can spread from cell to cell over time. So it’s really kind of on the forefront of science now -- is understanding how trauma leads to this tau being deposited and, again, what we can do to maybe prevent it from spreading. It could be a vaccine. It could be medications. We don’t know yet. But there may be ways to prevent that.
Sherdog.com: So is tau what causes brain degeneration or is it just a marker that degeneration is happening?
Bernick: Well, again, we don’t know, that’s a very good question. We don’t know that. What we would need to do is understand it probably first in animal models, and there are animal models of repetitive head trauma, and we may get some idea from that. But the smoking gun is that (tau) seems to be fundamental, or the characteristic finding, in Chronic Traumatic Encephalopathy. And there’s other findings as well. But somehow tau plays an important role.
Sherdog.com: Longtime MMA fighter and kickboxer Gary Goodridge is suffering from dementia, and it’s been attributed to the damage he’s taken in his career. Tell our listeners how brain trauma suffered in fights can translate into fighters not being able to remember things.
Bernick: In some sense, we don’t know -- that is what degree of exposure and trauma is necessary to cause the damage necessary to then cause a severe disease like that. We do know a couple things. One is it does seem, or it may appear, that you don’t have to get knocked out. It may be just the number of blows to the head, maybe just enough to stun you, may be enough to cause damage. And if you do that repetitively over and over again, you damage the cells; you, for some reason, produce this tau protein. This tau protein then spreads, and then if you accumulate enough damage -- particularly if it’s in areas of the brain that are crucial for memory, for reaction time, for emotion -- you’ll start getting the symptoms, these very obvious symptoms. I think the important thing for us is that once you have symptoms, you’re pretty far along down the line. What we’ve found from some of the preliminary data from our study is that you can actually have shrinkage in the brain, these structural changes, years before people become symptomatic. So we know something’s starting in the brain many years before they get to that point of Mr. Goodridge. And so that’s where you really want to intervene; you don’t want it to get to that point. Because once somebody has dementia, forget it. I mean, it’s just very difficult to manage.
Sherdog.com: What are some of the symptoms of this type of brain damage? Are they similar to some of the signs exhibited before Junior Seau’s death?
Bernick: With Chronic Traumatic Encephalopathy, some of the early symptoms are behavioral. So it’s increased impulsivity, increased depression, things like that, that can be actually the first manifestation of the disease, even before you develop more of the physical and the memory problems. So, you know, we’ll have to see if that’s what [Seau] has. It’s a tragic case any way you cut it, but it’s certainly possible that he may have suffered from that. I want to also preface this by saying that athletes are certainly entitled to have the same type of illnesses that anybody has. So, you know, if you’re retired and you get a change in lifestyle, change of status, there may be other reasons to cause some of the changes, not necessarily CTE. The case histories of many of these athletes is that they become more agitated, more volatile, more violent, so there’s no question that those behaviors can intensify as part of the Chronic Traumatic Encephalopathy. It just shows the difficulty of sorting this out clinically. Sometimes, you develop CTE, for example, and then you get depressed and then you start drinking or you use drugs. And so then it becomes hard to tease [out], well then, what part of the behavior is the drugs? And how much is the alcohol? But kind of the undercurrent of all this is the Chronic Traumatic Encephalopathy. I don’t think we can dismiss it, and, so, it makes it difficult to say for any specific case what specific factor caused the symptoms. And maybe it is a combination in certain people. But whatever it is, I think if we can eliminate that Chronic Traumatic Encephalopathy component, we may be on the right track to eliminate some of these other problems.
Sherdog.com: Why has CTE suddenly become so knowable?
Bernick: I think it’s just the attention. First of all, you have to look for it. In other words, unless you stain the brain in a certain way to look for tau and do more sophisticated neuro-pathological studies, you’re not going to find it. And, so, I think it was the attention that’s come from the NFL and such. Now we’ve studied more brains, and there just seems to be an abnormal amount of people -- athletes -- with CTE. And it’s probably there all the time; it’s just that nobody looked or we didn’t have the staining techniques to look. There was this recent article of a study from Boston University about the veterans coming back from Iraq who have blast injuries, passed away and at autopsy had changes of CTE from that exposure. It’s becoming clear that head trauma, and particularly repetitive head trauma, certainly raises your risk of developing this complication. And I think now we’re seeing it just across the board in different areas of society.
Sherdog.com: How is the study funded and is there any room to tap fight fans who buy tickets and pay-per-views to bolster it?
Bernick: We’ve got our study launched by money from a foundation; it’s called The Lincy Foundation, although it’s actually changed names. The Lincy Foundation was set up by Kirk Kerkorian, who’s a major owner in Las Vegas of the MGM Mirage organization and so on. So they got us started. And to continue studies like ours and others, you need funding. So where do you get that from? You can get that from the government, the National Institutes of Health, which we are applying to. The Department of Defense has interest in head trauma, so there’s an interest there. So the government may be one source; foundations may be one source. We do have to be a bit careful about some of the industry organizations. So getting money from the UFC or some of the boxing promoters, not that that’s bad -- and if that’s what you need to get this study completed, then that’s probably worth it -- but there’s always this concern about conflict of interest. That is, if your study is totally funded by an entity that may have an interest in the outcome; it doesn’t mean your outcome’s wrong, but you just have to be careful about that. So, actually, it would be ideal to just have consumers or people that, you know, just love the sport and want to see the sport enhanced and the athletes protected and safer [fund it]. That may actually in some sense be the best way to fund some of these important studies.
Sherdog.com: Over the years as MMA has struggled for acceptance in America, a key rallying cry has been that MMA is indisputably safer than boxing. Considering your study involves both boxers and MMA fighters, do you see any evidence of that?
Bernick: We did look at this, because obviously it’s a common question. And so far -- and you have to take our results as somewhat preliminary, probably now we have the full data on maybe 150 fighters -- there isn’t a huge difference between boxers and MMA guys. If you kind of match them for the number of fights they’ve had, their age, education and number of fights, there’s not a huge difference. There are some minor differences between the two in certain things, but all in all there’s not a huge difference. And it may be the fact that the fight might not be the important part. It actually might be the training. The fight, even if you have a championship fight, it might go 25 minutes. But it may be more important what you’re doing day in and day out in the gym, sparring, grappling. You know, as we’ve talked to fighters, a lot of them say, well, when you train, we may hold back a little, but sometimes, on the other hand, it depends who you train with. You know, you may be going all-out. And that may be where it’s happening the most, where most of the damage is happening, not so much the fight.
Sherdog.com: When you say there’s not a huge difference between boxers and MMA fighters, there’s not a huge difference in what exactly?
Bernick: Well, the two major outcome measures we have now and that we have results on is how people perform on their cognitive or mental testing. So this is like reaction time, memory, speed of processing information. And we test that by a computerized battery of tests that they take. So that’s one outcome measure. And then the other outcome measure is looking at, again, the size of certain areas of the brain, and that is comparing how many fights they’ve had with the size of certain areas. And, again, between boxers and MMA guys at the moment -- we may change our view as we get more fighters into the study -- it doesn’t seem like there’s a huge difference between the two.
Sherdog.com: So is it too much of a reach here, in 2012, knowing what we know, to say that MMA is safer than boxing?
Bernick: I don’t think there’s any evidence; there’s no evidence it’s safer. Maybe it’s safer, but we don’t have any evidence one way or another, to be honest with you.
Sherdog.com: There is an idea in combat sports that the more knockouts you suffer the more susceptible you are to being knocked out in the future because your ability to absorb a shot somehow deteriorates. I could never quite square the science of that in my head.
Bernick: I don’t know that. I don’t know if that’s lore. I can almost guarantee there’s no science behind that, because nobody’s really actually probably formally looked at that. So I don’t know; I don’t know that to be true. Again, maybe it is, but I’m not aware of that. It may be because you’ve been knocked out a couple of times, you’re starting to get changes in your brain that does slow your reaction time and does make changes that make you more susceptible to a knockout the next time. Now, we do know that there’s a phenomenon called a second concussion phenomenon, where if you have one concussion and then you go back too soon and then you have another one, it can actually cause kind of these devastating effects, swelling in the brain and stuff. That is very uncommon, and I don’t think it would be similar to what you’d be referring to. But it could be simply that, you know, if you’re knocked out enough, you probably are either not very good or you may be starting to have changes in the brain that is affecting your reaction time and your defense and so on.
Sherdog.com: The logical conclusion of the type of study you’re doing is that eventually you’ll be able to cull data that can end a fighter’s career. I imagine at some point there would be some friction with promoters if that prevents him and the fighter from making money.
Bernick: Well, yeah, that’s going to be up to the regulatory agencies. It definitely will affect the fighter and the promoter. But, really, for the benefit of the sport, you really probably don’t want tomato cans around, people that are just losing their skill. That doesn’t serve anybody. So I think, you know, it really benefits the sport itself to try to actually have people that are losing their skill because changes are happening in the brain to probably get out before they get more damage and lose their skills.
Sherdog.com: It might be self-evident, but tell us what’s at stake here. What is on the line for these fighters in terms of why this study is so important?
Bernick: I guess when you’re young, you don’t think about these things. But, of course, we see people further down the line, when you’re late 40s, 50s -- which is actually not very old -- or 60s, where you have families that become part of the equation that suffer from this. So not only do you in some sense lose the athlete themselves and their quality of life, but it affects families around them. Although people in combat sports make up a very small portion of society, in general, it’s an important component, in that it reflects not only fighting but other sports that involve contact, military, people who are injured with head trauma. All these different parts of society can end up the same way. And I think if we understand it in the sport of MMA or boxing, we can translate these types of things and really help people throughout society.