Below is an edited transcript from interviews with Charles Bernick of the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas. Bernick is the principal investigator of the Professional Fighters Brain Health Study.
What's this study you're undertaking?
The goal is really to understand, be able to diagnose and eventually be able to prevent the long-term effects of repetitive head trauma. And we're in a good position here in Las Vegas in that we have a lot of fights, we have a lot of fighters (and) the UFC's centered here.
So we embarked in 2011 and what it consists of is yearly comprehensive evaluations, including imaging of the brain of both MMA guys and boxers. The goal is to be able to follow these folks over time and see if we can detect the earliest changes of brain injury, be able to predict who may be at risk of developing these long-term brain complications and of course at some point be able to intervene.
What early results have you found?
We don't know how people were before. We don't know what their previous backgrounds were. But with all delineations of that, there have been a number of findings.
One is, just as you'd expect, the more exposure a fighter has -- and we measured exposure with number of fights, frequency of fighting (or) fights per year and years of fighting and we have a composite index where it includes all these factors -- we can see a number of changes. So we can see lower volumes of different areas of the brain because we can measure the size of different areas. We see more disruption in fibers. We see changes in what we call functional conductivity so just the way different areas of the brain interact so you can actually measure that -- with more exposure there's more disruption of that. There seems to be a relationship between weight classes and the effect of exposure so that ... generally lower weight classes for the same amount of fights have lower volumes. And this is at a group level. This is looking at the whole group rather than looking at one individual.
Do you study both boxers and MMA fighters?
That's correct, but we look at them separately, too. It turns out that the boxers in general ... have lower volumes of different areas of the brain in general than the MMA guys. But there's still the same relationship so that even in MMA the more exposure a fighter has there's a relationship with lower volumes and more disconnections and so on. It's what you might imagine, no matter how you're getting hit, maybe MMA they don't get hit as much, but still the more you get hit, the more likely you're going to have damage -- more volumes, more disruption of fibers, more imperative conductivity. I don't think MMA people are immune to it. But whether you look at them separately or together you still get these findings.
Have findings pointed to one sport being more dangerous than the other?
I don't think we're at a point where we can actually say that one sport's any more dangerous than another because there's so many other factors that are hard to sort out and we just don't have the numbers yet to sort that out.
MMA guys, for example, tend to be more educated, so you have to factor that in, education seems to have a protective effect, at least when you test things like reaction time and cognitive testing.
Are there a certain number of hits that start to cause serious damage?
We looked at that. We were curious ourselves. Now again we've only looked at the volumes of the brain and you really can't detect, again, from just a group level, any real associations until you reach five years of professional fighting.
(But) you start developing these structural changes and then people demonstrate actual symptoms later on. So the cognitive part you really don't see changes until further along in their careers. So there probably is a time that maybe the brain can absorb a certain amount of injury, but then if you exceed that, if you go over that ledge, then you can see continued decline with more and more exposure.
What do volumes mean?
We have the technology now using just an MMA scan to measure the size of certain areas of the brain. For example, we know where the memory area is. We know there's areas deep in the brain that involve motor control and movement and speed of processing and interestingly those areas that seem to be affected, at least that we find, in fighters. So we can divide the brain up into different anatomical areas and measure pretty precisely the size of these areas and we know what's kind of normal, so we know what it should be, and plus for any one individual we can track it over time so we can see if it's continuing to generate.
The thought about that is as volumes decrease that's probably due to loss of brain cells, damage to brain cells and the brain fibers. It's in some sense a measurement of damage.
Is there a recommendation for fighters now?
No. There's just not enough information. There's just so little known that can help guide us specifically. Hopefully what will come of this is some understanding of well should you have a period of rest before if you sustain some type of concussion. In terms of sparring, how much should you spar? Should you limit sparring? Things like that.
Nobody really knows these issues. Is it worse to get a couple really severe blows or concussions? Or is it an accumulation of a lot of little blows that cause damage? Nobody knows. Nobody really knows. So we have all these questions and it's really hard to guide fighters in the field now. Our hope at least initially that we might be able to come up with some guide or composite index, which is you can easily calculate number of fights per year versus years of fighting and you just factor that in and that can give you a score that would indicate when that person needs to have greater surveillance or needs to be tested more frequently or when they may need to fight less frequently. So the hope is that we can come up with these measures and tools but we don't have them now.
Our initial thought talking to the statisticians is that we would at least need five years of following somebody over time and the longer we can go the better it is, the more we'll learn. But I think if we can get a good five years and have enough people follow up with it, I think we'll have at least a fair sense.
Based on evidence, would you say any kind of fighting is bad?
Well. Um. Blows to the head are definitely not good. But I think realistically these are common sports. Football for example might be much worse than boxing or MMA. I think our goal is not, our approach is not to say, 'Ban these sports. Don't get involved.' They're clearly not good for your brain. But are there things that we can learn that can protect people who are involved in it. So that's what we're shooting for.
So, yeah. If it was my son I don't think I would advise him to go into a contact sport like this. But people do. On the flip side, we talk to these guys that come in, these people are from, their backgrounds are not the best, it's not like they have a lot of other opportunities, and there's a lot to say for the discipline that's involved in martial arts and a lot of the fighters I think are at their best when their fighting and in terms of what they get out of fighting.
There's certainly positive things that come out of these sports, it's just how you provide as much safety as you can. We just need to learn more about that.
How do you assess and study the fighters?
They come in. It takes about two hours all together. The MRI scan itself takes about 50 minutes. They get an MRI scan and it's more than just a routine MRI scan. Not that it's anything more than any other MRI scan can do. It's just that we have different ways to analyze it so it takes longer to do the testing. So we do an MRI scan and in the MRI we do measure the volumes. We measure the fiber tracks, it's called BTI. We measure the conductivity, the functional connections and we measure blood flood. They get all that.
Then they get a computerized test of their cognitive function. So reaction time, memory, speed of processing information and so on. We get a speech sample from them because speech, at least in fighters, boxers, it's a common thing to be affected. So we get a speech sample from them. We do surveys of their mood -- so depression, impulsivity, things like that. We get a blood sample from them and that's to look for genetic markers, so we extract the DNA so we get the genetics. We also save the serum and the plasma from the blood to look for perhaps markers in the blood that can tell us a disease is starting. And then they get a balance test -- again, it's something that may be affected relatively early. And then they get a general neurological evaluation. So we can get through actually all of this stuff in two hours. It's not a long visit. And they're seen once a year.
If somebody comes into our study and they're within the United States we'll fund their way back. The key again is getting these guys back so we do whatever we can to get them back. Also, for the benefit of them and the incentive for people to participate because you'd say, why would anybody want to participate in this study? The information is confidential. No matter what we find we only share it with the participant. And then the second is that because in terms of licensing, many states of course require an MRI scan, which they would get for free as part of the study and we also the fighters, because we do draw blood for our study, we offer the blood test that many of them need for just their yearly licensure. So hopefully there is an incentive for them not just to help the field but they also get something practical out of it.
Who funds the study?
The Cleveland Clinic has several sites in the country and one of the sites is here in Las Vegas and the Las Vegas site is strictly focused on brain health and when you say brain health it's really neuro-degenerative diseases of the brain, so Alzheimer's, Parkinson's, ALS and so on. Well, it turns out that probably the newest neuro-degenerative disease is CTE so that's how our interest came in just the subject because no one knew much about it. We got funding, we ran it past our Nevada Athletic Commission and some of the big promoters -- Top Rank and UFC and so on -- and everybody was very supportive in helping make this happen. So we got funding from a foundation, it's called the Lindsey Foundation. That got us started. It is quite expensive just because of the number of MRIs.
Does sparring factor into your analysis?
They way we do it is, because we're not there, so we rely on the participant's report, but we ask them two things: One is how much sparring they've done within two weeks of the study visit? And then what is their customary about of sparring per week? These aren't exact number, but at least they give us some sense of how each person trains and what we might expect.
Do volume losses in the brain equate to any specific brain disease?
We don't know. It's not clear that they do. But they might. In other words, it's not normal to have volume loss. But we don't know. In fact that's what we're really trying to determine in this study is: Are there markers that can be utilized either by the athlete themselves or regulatory agencies that are indicators of damage occurring or a disease developing.
Because currently there is no marker so athletic commissions and even fighters themselves, unless they really start becoming symptomatic, there's no way to know if there's a problem starting. So the hope of doing these type of imaging studies and such are can we identify a marker that could be used by regulatory agencies by athletes to at least identify individuals who may need more surveillance, who may need to be followed a little more closely for changes over time and such.
Pathologically it is. So what we know of CTE is there's volume loss in a lot of different areas. The problem is we really don't know how CTE evolves. Most of the information about it occurs from autopsy studies but there you have a bias because you're seeing the end result of people who at this point are usually symptomatic. But we don't know what the changes are that leads to that and that's going to take a lot of work to figure that out because in some sense we don't have the diagnostic test so it's not like cholesterol you get a blood test and you know you have high cholesterol.
With CTE there is no test that tells us that that person has it. That's a goal of our study to see can we identify a diagnostic marker or some way to at least have some better understanding of the process that leads to CTE, which we don't have now.
Is there a difference between boxers and MMA fighters?
Absolutely. Again, this is looking at just one point in time, but boxers clearly have a greater volume loss, again, given the same number of fights, boxers have greater volume loss and why that is, is speculative. The obvious thing is well they get hit in the head more. But it is what it is. There are certainly other factors that can account for it. Boxers, there may be differences in the socio-economic status between boxers and MMA guys and boxers may start out with poorer nutrition or other environmental things that they start out with a lower brain size to begin out with. Just nobody knows. We definitely found a difference.
Have you seen any concerning or jarring fighters?
We definitely see people who are symptomatic. This is primarily in our retired fighters. So there's no question, of course everybody in the business probably sees that. So we know there are fighters that are affected. But the active fighters it's harder to discern just talking to them and so on. But clearly some fighters score at an impaired range in some of their testing and cognitive tests and such. We don't know again if that's where they've started from. That's why following them over time is so critical to see if they continue to decline.
Even just starting out, are you still seeing changes in the brains of young fighters?
To some degree. It is a range, a gradient. Some of the fighters that have very low number of professional fights still show changes. Many of them have had amateur fights so it's not like they start from point zero. It certainly seems like it takes exposure to head trauma to show these changes. But even at a lower level of exposure you can see changes in some individuals. That's probably what I would like to emphasize again. It's not that everybody that has one fight is going to show changes in their brain. People are different. Some people fight for a long time and have no problems. Some people fight for little and have a lot of problems. Again, there are so many variables that probably play into it.
Maybe the type of fighter you are, how hard you go in training, do you go against bigger guys in training, do you have some genetic predisposition, did you have an injury as a child and that's what you're seeing? There's just so many other things that could factor in. I just don't want the impression that everybody that's exposed is going to have these changes.
All we know is in general, at a group level, this is what we're finding, that the more exposure you have the greater the association is with these changes to the volume loss and the disruption of the fibers and so on, cognitive changes.
Do you have an initial recommendation based on your early research?
I don't know if we can say anything firmly from the data we have now. Just given what we have, plus the whole body of information that we have I think we could say certain things. One is that there may be, for example in our study, we've used a 'composite index' but it's basically just a formula where you just put in the number of fights they've had, number of fights per year they've had and you could out with a number and the higher the number the more likely there is going to be some changes. I think at some point regulatory agencies should look at a formula such as that, that might be able to at least select out those individuals who may be at a higher risk of developing changes and those people may need more surveillance.
Different states have different requirements. I think we need to be a little more scientific in terms of how we actually monitor at least professional fighters.
I think we can come up with some general suggestions and yeah those probably should be given to trainers. I think trainers need to be educated about head trauma and the issues involved and how they train their fighters as far as that goes. Some may be doing these fighters a disservice. A sparring issue for example, if you're having someone really going hard in sparring and you don't really give them adequate time to rest before their competition I think that may be a disservice to the fighter. There are some things just from what we know can be discussed with trainers and hopefully implemented.
That's probably not the smartest thing to do. I'm not saying we have it down perfect but just given everything we do know that's probably not a good things to do. So educating trainers and fighters themselves about some of these things -- what traditionally they've done may be doing them a disservice.
Would that formula include sparring frequency?
Ideally it probably would. What we've used because the sparring history--the things we can actually accurately get is their record. We know how many professional fights they've had. We know how frequently they're fighting. Those things are verifiable. So that's why we've used them. If there's some way to get information on truly how much they're sparring and not relying totally on what they're telling you because people are probably going to assume some people might downplay they're not doing it as much as they're probably are. We just use things we know we can verify. But even using that, even using the composite index that we have may be a tool that athletic commissions could adapt and use as part of their regulatory requirements.
That makes sense. Even if you're in a championship fight and you go 25 minutes that's compared to all the volume of blows that you're getting leading up to that it's a small amount. Probably a lot of the injury, whether it's football or MMA or boxing is often during the training part and again maybe one way to intervene is to educate people. I know they're making changes in football regarding that and maybe other contact sports need to follow.
We have no retired MMA guys. We have like one. I know it's a young sport. But it would be really interesting to survey retired MMA guys and kind of see how they're doing.