1
|
Stellpflug SJ, Dalrymple KA, Stone D, Southgate S, Bachman DS, LeFevere RC, Hasan J, Zwank MD. Impact of repeated sportive chokes on carotid intima media thickness and brain injury biomarkers in grappling athletes. PHYSICIAN SPORTSMED 2024:1-9. [PMID: 38857060 DOI: 10.1080/00913847.2024.2366154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/06/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE Vascular neck compression techniques, referred to as 'chokes' in combat sports, reduce cerebral perfusion, causing loss of consciousness or voluntary submission by the choked athlete. Despite these chokes happening millions of times yearly around the world, there is scant research on their long-term effects. This pilot study evaluated whether repeated choking in submission grappling impacts the carotid intima media thickness (CIMT) and brain injury biomarkers (NFL, hGFAP, t-Tau, and UCH-L1). METHODS Participants (n = 39, 29 male; ages 27-60 years) were assigned to one of two study arms: Grapplers (n = 20, 15 male) and 19 age/sex/body size matched controls. Grapplers had been exposed to >500 choke events while training for >5 years in a choke-inclusive sport. Exclusion criteria were recent TBI or deficits from a past TBI or stroke. Bilateral ultrasound measurement of the CIMT was performed, and blood was collected for quantitative analysis of four brain injury markers. Subgroup analyses were performed within the Grappler group to account for blunt head trauma as a possible confounder. RESULTS There was no overall difference in CIMT measurements between Grapplers (mean 0.55 mm, SD 0.07) and Controls (mean 0.57 mm, SD 0.10) p = 0.498 [95% CI -0.04-0.08], nor were there CIMT differences between Grappler subgroups of blunt Trauma and No-Trauma. There were no significant differences in any biomarkers comparing Grapplers and Controls or comparing Grappler subgroups of Trauma and No-Trauma. CONCLUSION This study found no significant difference in CIMT and serum brain injury biomarkers between controls and grapplers with extensive transient choke experience, nor between grapplers with extensive past blunt head trauma and those without.
Collapse
Affiliation(s)
| | | | - Daniel Stone
- Department of Emergency Medicine, Regions Hospital, Saint Paul, MN, USA
| | - Samuel Southgate
- Department of Emergency Medicine, Regions Hospital, Saint Paul, MN, USA
| | - David S Bachman
- Critical Care Research Center, HealthPartners, Saint Paul, MN, USA
| | - Robert C LeFevere
- Department of Emergency Medicine, Regions Hospital, Saint Paul, MN, USA
| | - Jaan Hasan
- Department of Emergency Medicine, Wyckoff Heights Medical Center, Brooklyn, NY, USA
| | - Michael D Zwank
- Department of Emergency Medicine, Regions Hospital, Saint Paul, MN, USA
| |
Collapse
|
2
|
Harrington WB, Fugler PR, Midkiff T, Christensen SJ, Miller E. Exploring Choke Holds in Brazilian Jiujitsu Athletes: A Demographic Study. Cureus 2024; 16:e60618. [PMID: 38894780 PMCID: PMC11182763 DOI: 10.7759/cureus.60618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Brazilian jiujitsu is a relatively new sport that has grown exponentially in popularity along with the growth of the Ultimate Fighting Championship (UFC). In jiujitsu, there are a variety of submissions with a choke hold being one of the most popular. There is a subset of athletes in jiujitsu who believes chokes are safe. However, there have been case reports of relatively young athletes suffering strokes secondary to internal carotid or vertebral artery dissections after being placed in choke holds. There have been manuscripts describing the injury profile in jiujitsu, but none mention stroke or dissections. This study evaluated how frequently chokes happen in jiujitsu and if athletes have ever experienced symptoms consistent with cervical artery dissection (CAD). Additionally, this study aimed to describe the training frequency and baseline demographics of jiujitsu athletes. Methods A survey was distributed throughout social media platforms which asked both quantitative and qualitative questions regarding athlete training. The survey consisted of 28 questions which collected largely baseline grappling information about the participants such as how long they trained, how often they spar, favorite submission, how frequently they are choked, etc. This data was then analyzed using odds ratio and one sample t-test to evaluate for statistical differences. Results A total of 521 participants were included in the analysis. The participants were mostly male (84.7%), trained for four years, four times per week; 99.8% (520) participated in sparring, with an average age of 37; and 55.7% (290) have experienced symptoms consistent with CAD. Descriptive statistics revealed that individuals who were 37 years of age or younger were more likely to experience symptoms consistent with CAD (odds ratio: 1.5337 (95% confidence interval (CI): 1.0827-2.1727). Athletes that were 37 years of age or younger have been training for fewer years (4.7 years vs 8.8 years) but train more days per week (4.03 times per week vs 3.76 time per week), drill for a longer amount of time (46.8 minutes per class vs 38.3 minutes per class), attend longer classes (81.12 minutes vs 72.3 minutes), and train for a longer period of time per week (338.5 minutes vs 274.6 minutes) than athletes over 37 years. All previously mentioned variables were analyzed using a one sample t-test and were significant at the α = 0.05 level. The lone qualitative question regarding the term "train brain" revealed that of those who experienced it, 84.1% (58) described it as a cognitive/physical impairing event. Conclusion Jiujitsu athletes train multiple times per week and are frequently exposed to choke holds. There is no literature to examine the long-term effects of these chokes on the athlete's cervical vasculature. Additional studies should be conducted to evaluate the effects of the repetitive stress placed on these vessels.
Collapse
Affiliation(s)
- William B Harrington
- Medical School, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Patrick R Fugler
- Emergency Medicine, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Tatiana Midkiff
- Physiology, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | | | - Eric Miller
- Surgery, Centra Bedford Memorial Hospital, Bedford, USA
- Surgery, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| |
Collapse
|
3
|
Hasegawa ME, Obana KK, Ishikawa KM, Tamate TM, Chang SB, Crawford SN. Increasing trend in Brazilian Jiu Jitsu injuries presenting to U.S. emergency departments - a 10-year analysis and injury profile. PHYSICIAN SPORTSMED 2024; 52:167-174. [PMID: 36995123 DOI: 10.1080/00913847.2023.2197898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE Evaluate injury trends in Brazilian Jiu Jitsu (BJJ) participation by presenting to U.S. emergency departments over a 10-year period and formulate an injury profile. METHODS The U.S. Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS) database was queried for martial arts related injuries from 1 January 2012 to 31 December 2021. Codes and narratives were examined to compile data for patients sustaining BJJ-related injuries. RESULTS From 1 January 2012 to 31 December 2021 there were 7,722 (NE = 282,315) ED-diagnosed martial arts related injuries with 911 (NE = 36,023) BJJ-related injuries identified. Regression analysis demonstrated an increasing trend in the annual incidence of Brazilian Jiu Jitsu injuries presenting to the ED (R2 = 0.934; SE = 2.069: p < .0001). Average age was 25.68 years of age (range 4-83). The most common injury diagnoses were sprains/strains and other/not listed at 27.68% and 26.39%. The most commonly injured body parts were the upper trunk, and the shoulder comprising 13.66% and 12.14% of injured body parts, respectively. The most commonly fractured region was toes, at 14.15% of all fractures. The most common dislocations occurred at the shoulder and knee, at 32.49% and 28.45% of dislocations, respectively. The most common mechanisms of injury specifically identified were indeterminate contact between players, fall onto ground, or fall onto another player comprising 18.62% and 17.17%, of injuries, respectively. CONCLUSION There was an increasing trend of BJJ-related injuries presenting to U.S. Emergency Departments. The most common diagnoses and body parts injured were sprains/strains and upper trunk and shoulder, respectively. The most commonly fractured and dislocated regions were toes and shoulder, respectively. The most common mechanisms of injury were indeterminate contact or falling. This study provides novel information concerning trends in injury and injury profiles for Brazilian Jiu Jitsu related injuries.
Collapse
Affiliation(s)
- Morgan E Hasegawa
- University of Hawai'i, Division of Orthopaedics- Department of Surgery, Honolulu, HI, USA
| | - Kyle K Obana
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Kyle M Ishikawa
- John A. Burns School of Medicine Department of Quantitative Health Sciences, University of Hawai'i, Honolulu, HI, USA
| | - Trent M Tamate
- University of Hawai'i, Division of Orthopaedics- Department of Surgery, Honolulu, HI, USA
| | - Shaun B Chang
- University of Washington Department of Orthopaedics, Seattle, WA, USA
| | - Scott N Crawford
- University of Hawai'i, Division of Orthopaedics- Department of Surgery, Honolulu, HI, USA
- Straub Medical Center, Department of Orthopaedics, Bone and Joint Centers, Hawai'i Pacific Health, Honolulu, HI, USA
| |
Collapse
|
4
|
Stellpflug SJ, Dummer MF, Martin CD, Vera JA, LeFevere RC. Cervical Artery Dissections and Ischemic Strokes Associated with Vascular Neck Compression Techniques (Sportive Chokes). J Emerg Med 2022; 63:49-57. [PMID: 35934648 DOI: 10.1016/j.jemermed.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/03/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Strangulation as a fight-finishing maneuver in combat sports, termed "choking" in that context, occurs worldwide millions of times yearly. This activity can be trained safely, but devastating injuries can occur. OBJECTIVE Our aim was to present a case series of cervical artery dissections and ischemic strokes associated with sportive choking. Sharing these cases is meant to draw awareness, to assist emergency physicians in caring for these athletes, and to provide a platform for further research. METHODS Institutional Review Board approval was obtained. Participants consented for medical information transfer and anonymous academic reproduction. The minimum medical record information necessary for inclusion was a report of diagnosis-confirming advanced imaging. Participants were contacted for primary information in addition to what the medical records could provide and to confirm some information in the record (e.g., pertinent medical history, demographic characteristics, choking event description, medical care, and commentary on their current health). Medical records and additional first-hand information were reviewed and participants were included if they had a diagnosed dissection or stroke likely associated with a sportive choke. RESULTS Ten cases met all criteria for inclusion. There were 5 cases of carotid artery dissection, 3 cases of vertebral artery dissection, and 2 cases of ischemic stroke without dissection. Nine of 10 participants survived and 3 of 10 have returned to submission grappling training. CONCLUSIONS Cervical artery dissections and ischemic strokes can occur in association with sportive choking. Emergency physicians must be aware of the widespread nature of this activity and must be vigilant in approaching management of patients with symptoms consistent with these injuries.
Collapse
Affiliation(s)
| | - Matthew F Dummer
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| | | | - Joshua A Vera
- Hazel Hawkins Memorial Hospital, Hollister, California
| | - Robert C LeFevere
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| |
Collapse
|
5
|
Stellpflug SJ, Weber W, Dietrich A, Springer B, Polansky R, Sachs C, Hsu A, McGuire S, Gwinn C, Strack G, Riviello R. Approach considerations for the management of strangulation in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12711. [PMID: 35445212 PMCID: PMC9013263 DOI: 10.1002/emp2.12711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
Patients with a history of strangulation present to the emergency department with a variety of different circumstances and injury patterns. We review the terminology, pathophysiology, evaluation, management, and special considerations for strangulation injuries, including an overview of forensic considerations and legal framework for strangulation events.
Collapse
Affiliation(s)
| | - William Weber
- Section of Emergency Medicine The University of Chicago Chicago Illinois USA
| | - Ann Dietrich
- Department of Pediatrics and Emergency Medicine University of South Carolina School of Medicine Columbia South Carolina USA
| | - Brian Springer
- Department of Emergency Medicine Wright State University Dayton Ohio USA
| | - Robin Polansky
- Department of Emergency Medicine Cedars‐Sinai Medical Center Los Angeles California USA
| | - Carolyn Sachs
- Department of Emergency Medicine University of California, Los Angeles Los Angeles California USA
| | - Antony Hsu
- Department of Emergency Medicine St. Joseph Mercy Hospital Ann Arbor Michigan USA
| | - Sarayna McGuire
- Department of Emergency Medicine The Mayo Clinic Rochester Minnesota USA
| | - Casey Gwinn
- Training Institute on Strangulation Prevention Alliance for Hope International San Diego California USA
| | - Gael Strack
- Training Institute on Strangulation Prevention Alliance for Hope International San Diego California USA
| | - Ralph Riviello
- Department of Emergency Medicine The University of Texas: San Antonio San Antonio Texas USA
| |
Collapse
|
6
|
Doyle-Baker PK, Mitchell T, Hayden KA. Stroke and Athletes: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910047. [PMID: 34639349 PMCID: PMC8507848 DOI: 10.3390/ijerph181910047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/17/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke that occurs in athletes. The risk of injury to the neurovascular structures may depend on the type of sport involvement, although, sport-specific incidence rates are not known. Therefore, the goal of our scoping review was to provide some guidance to better inform the development of a context-fit stroke model by summarizing studies on a broad research topic related to stroke or cerebrovascular accident in sport based on a strict athlete definition. We used the guidance of Arksey and O’Malley’s five-stage-process for a scoping review. Databases included MEDLINE(R) Epub Ahead of Print, In-Process & Other Non- Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), and Embase (OVID databases); CINAHL Plus with Full Text, SportDiscus with Full Text (Ebsco databases); and Scopus. Publication dates were from 1979–2020 across nine different countries resulting in 39 individual cases of stroke with an athlete age range of 14–56 years (95% male). The major inciting event(s) prior to stroke onset were headaches (38.4%), head trauma (30.7%), and neck injury and/or vertebral artery dissection (20.5%). Several sporting activities were represented with American football as the most prevalent (30.7%). In summary, we found that sports with an aspect of impact, collision, or microtrauma can lead to subsequent stroke. These sport-related traumatic events were often difficult to diagnose because of the longer interval before ischemia occurred. Therefore, health care providers should be particularly attuned to the possibility of stroke when evaluating athletes presenting with or without neurological deficit.
Collapse
Affiliation(s)
- Patricia K. Doyle-Baker
- Human Performance Lab, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada;
- School of Architecture, Planning, and Landscape, University of Calgary, Calgary, AB T2N 1N4, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB T3B 6A8, Canada
- Correspondence: ; Tel.: +1-403-220-7034
| | - Timothy Mitchell
- Human Performance Lab, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - K. Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, AB T2N 1N4, Canada;
| |
Collapse
|
7
|
Stacey BS, Campbell Z, Bailey DM. Elevated cerebral perfusion and preserved cognition in elite Brazilian Jiu-Jitsu athletes: Evidence for neuroprotection. Scand J Med Sci Sports 2021; 31:2115-2122. [PMID: 34343371 DOI: 10.1111/sms.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 12/01/2022]
Abstract
Brazilian Jiu-Jitsu (BJJ) is a popular martial art that exposes participants to recurrent intermittent asphyxiation due to controlled application of neck chokes. To what extent the sport impacts the regulation of cerebral blood flow (CBF) and cognition has not been examined. This study compared eleven elite Brazilian Jiu-Jitsu athletes (aged 30 ± 8 y) who trained 12 ± 6 hours/week for 8 ± 4 years against eleven cardiorespiratory fitness (CRF)- and age-matched controls. Internal carotid (ICA) and vertebral artery (VA) blood flow were measured via duplex ultrasound to determine global cerebral blood flow (gCBF). Mild cognitive impairment and sub-domains of memory, attention/concentration/visual motor coordination, and executive function were determined by psychometric testing. There was no evidence of mild cognitive impairment in the athletes, and cognitive function was comparable between groups (all p > 0.05). In contrast, resting gCBF was selectively elevated in the athletes (741 ± 186 mL∙min-1 vs. 573 ± 166 mL∙min-1 , p = 0.037) due to combined differences in ICA (+65 mL∙min-1 , p = 0.079) and VA (+19 mL∙min-1 , p = 0.277) flow. In conclusion, the sustained elevation in resting cerebral perfusion provides preliminary evidence for adaptive neuroprotection that is independent of CRF and likely mediated by choke-induced cerebral preconditioning and/or lifelong exposure to BJJ-specific high-intensity interval training.
Collapse
Affiliation(s)
- Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, UK
| | - Zac Campbell
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, UK
| |
Collapse
|
8
|
Stellpflug SJ, Schindler BR, Corry JJ, Menton TR, LeFevere RC. The safety of sportive chokes: a cross-sectional survey-based study. PHYSICIAN SPORTSMED 2020; 48:473-479. [PMID: 32271638 DOI: 10.1080/00913847.2020.1754734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives: Sportive choking or strangling, known as a 'choke' in the combat sports community, is the practice of compressing the jugular veins and carotid arteries to threaten unconsciousness by lowering cerebral perfusion pressure. This is commonly practiced within combat sports and police/military combatives. The safety profile of sportive choking is underrepresented in the literature. The authors sought to explore the safety of sportive chokes. Methods: A convenience sample of visitors to two combat sports internet forums completed an anonymous web-based survey on choking experience and related symptoms. Descriptive statistics were used to describe the obtained data. Bivariate analysis was performed to elaborate on relationships between grappling experience and the number of times choked, between the number of times choked with pre-syncope/syncope, and between the duration of symptoms and the number of times choked with pre-syncope/syncope. Results: Overall, 4421 individuals completed the survey. One hundred and fourteen were excluded, leaving 4307 analyzed respondents. Ninety-four percent were male, 89.2% were ages 18-44 years. Seventy-nine percent had >1 year of grappling experience and 30% had >5 years. Of the 4307, 1443 (33.5%) reported being choked >500 times, 3257 (75.7%) have been choked to near-syncope, and 1198 (27.8%) have been choked unconscious. Two of the 4307 (0.05%) reported ongoing symptoms from chokes. Of the respondents, 94.3% felt applying a choke would be a safe and effective way to control a street fight; 83.6% felt that vascular neck restraint, the police combative equivalent of sportive choking, would be appropriate as an alternative escalation of force option. Conclusion: Based on a convenience sample of 4307 respondents' self-reported data, sportive choking appears to be safe. Only 0.05% experienced ongoing symptoms, which were likely not related to brain ischemia.
Collapse
Affiliation(s)
| | - Broc R Schindler
- Department of Emergency Medicine, Regions Hospital , Saint Paul, MN, USA
| | - Jesse J Corry
- Department of Neurology, United Hospital , Saint Paul, MN, USA
| | - Thomas R Menton
- Saint Paul Police Department, Training Unit , Saint Paul, MN, USA
| | - Robert C LeFevere
- Department of Emergency Medicine, Regions Hospital , Saint Paul, MN, USA
| |
Collapse
|
9
|
Serkin Z, Le S, Sila C. Treatment of Extracranial Arterial Dissection: the Roles of Antiplatelet Agents, Anticoagulants, and Stenting. Curr Treat Options Neurol 2019; 21:48. [DOI: 10.1007/s11940-019-0589-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|