CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Youth Participation and Injury Risk in Martial Arts Rebecca A. Demorest, MD, FAAP, Chris Koutures, MD, FAAP, COUNCIL ON SPORTS MEDICINE AND FITNESS

The martial arts can provide children and adolescents with vigorous levels abstract of physical exercise that can improve overall physical fi tness. The various types of martial arts encompass noncontact basic forms and techniques that may have a lower relative risk of injury. Contact-based sparring with competitive training and bouts have a higher risk of injury. This clinical report describes important techniques and movement patterns in several types of martial arts and reviews frequently reported injuries encountered in each discipline, with focused discussions of higher risk activities. Some This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have of these higher risk activities include blows to the head and choking or fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process submission movements that may cause concussions or signifi cant head approved by the Board of Directors. The American Academy of injuries. The roles of rule changes, documented benefi ts of protective Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. equipment, and changes in training recommendations in attempts to reduce Clinical reports from the American Academy of Pediatrics benefi t from injury are critically assessed. This information is intended to help pediatric expertise and resources of liaisons and internal (AAP) and external health care providers counsel patients and families in encouraging safe reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations participation in martial arts. or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. INTRODUCTION All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, The term martial arts is derived from the “arts of Mars” (Roman god revised, or retired at or before that time. of war) 1 and presently encompasses formal combat traditions that DOI: 10.1542/peds.2016-3022 can be practiced for self-defense, competition, physical fitness, motor PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). development, and emotional growth. More than 6.5 million children Copyright © 2016 by the American Academy of Pediatrics participate in some form of martial arts in the United States. 2 Martial FINANCIAL DISCLOSURE: Dr Koutures is a consultant to Neural arts can be effective tools for building muscle strength and balance and Analytics for their clinical trials. Dr Koutures also receives royalties enhancing flexibility in children and adolescents, 3, 4 as well as positive from SLACK Publications. Dr Demorest indicated she has no fi nancial interventions and activities in which to help build cognitive function, relationships relevant to this article to disclose. self-esteem, self-respect, and self-awareness.5 – 7 FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they Various types of martial art disciplines can be categorized as striking have no potential confl icts of interest to disclose. (using blocks, kicks, punches, knees, and elbows to defend oneself while on one’s feet 8), grappling (taking an opponent to the ground to achieve a dominant position or use a submission hold to end a fight), weapon- To cite: Demorest RA, Koutures C, AAP THE COUNCIL ON based, or low-impact/meditative style with overriding philosophies that SPORTS MEDICINE AND FITNESS. Youth Participation and Injury Risk in Martial Arts. Pediatrics. 2016;138(6):e20163022 are oriented toward combat, health, or spirituality. Mixed martial arts

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 6 , December 2016 :e 20163022 FROM THE AMERICAN ACADEMY OF PEDIATRICS (MMA) involves the combination of • variations in injury definitions Risk stratification in studies of different types of martial arts in a (eg, cessation of match, observed martial arts does not show consistent competitive venue. injury, reported injury, time loss results. Results are inconsistent as injury); to whether age (younger versus The practice of a particular martial older) and level (beginner versus • differences in study methods art or MMA involves both training professional/advanced) place an (competition injuries [more and possibly competitive activities. individual at increased or decreased commonly studied] versus training All martial artists execute forms, risk for injury. 11, 14 – 20 A 2005 study injuries [less commonly studied]); which are individualized repetitive spanning 5 martial arts disciplines practice of movements, striking/ • accounting mostly for acute but not (Shotokan karate, Aikido, taekwondo, blocking techniques, and potential chronic injury; kung fu, and tai chi) found that use of weapons without any contact people 18 years or older were 4 • lack of consistency across studies with objects or other performers. Not times more likely to sustain an injury in use of protective equipment; and all martial arts practitioners progress compared with those younger than to combat practice or competition. • lack of detailed, accurate, complete, 18 years and that competitors with For those martial arts disciplines or any reporting (recall bias, at least 3 years of experience were that involve combat elements, a retrospective self-reporting, 2 times more likely to sustain injury common training practice involves postmatch video recall). 9, 10 compared with less experienced competitors. 14 Participants younger sparring. Sparring is defined as Most studies to date of martial arts than 18 years doubled their risk of actual combat or fighting between comprise data largely from the injury with every 2 additional hours 2 individuals that uses particular adult population; however, when of training per week after the first 3 techniques of blocking, kicking, pediatric data were available, they hours, and those training for more striking, and takedowns (throws were evaluated and are noted in this from the standing position 8), as than 3 hours per week had an overall report. 14,15 taught by each style of martial arts increased injury risk. One study and overseen by instructors. Sparring In a cumulative epidemiologic study of children and adults participating may begin at any age, as directed by of pediatric martial arts, overall in martial arts found that those the martial arts instructor, and often reported injury rates varied from younger than 10 years had an overall after learning basic movements/ 41 to 133 injuries per 1000 athletic lower injury rate per 1000 athletic forms. Martial arts students are exposures. 11 In a 2006 study, an exposures compared with all other often categorized according to age estimated 128 400 children aged ≤17 age groups; however, when adjusting and belt color, with advanced belt years (mean age, 12.1 years; 73% for exposure time, the 10- to 14-year- designations earned after proper male) were treated in US emergency old age group had a higher injury risk execution of forms often combined departments for martial arts–related per minute exposed compared with 18 with sparring. injuries from 1990 to 2003, with the open division. To what degree most injuries attributable to karate skill and age may help or harm Some martial arts styles require (79.5%).2 Generally, martial arts athletes continues to be researched. participants to use soft gear intended injuries are not life-threatening Sex stratification in studies for head and body protection. Martial (abrasions, contusion, sprains, also yields inconsistent arts competitions are formal and and strains); however, fractures, results. 2, 10, 11, 14, 15, 17, 21 Without ritualized time-measured events neck injuries, dental injuries, and significant participation of female with referees often awarding points concussions do occur. 2, 11 Overall subjects in many of these studies, and supervising conduct of the fracture rates of 10% and higher more research is needed. performers. of all documented martial arts injuries have been described in Injuries specific to different martial multiple articles.2, 11 – 13 Most reported art forms are detailed in the following EPIDEMIOLOGY OF PEDIATRIC AND pediatric martial arts injuries sections. Not all disciplines are ADOLESCENT MARTIAL ARTS INJURIES are acute. 11 Free sparring during covered, because not all disciplines Pediatric and adolescent martial tournaments seems to cause many have been studied in detail, especially 14 arts injuries and injury risk are very overall injuries in martial arts. The with children and adolescents. Of difficult to quantify, stratify, and nature of the martial art (kicking, note, despite kicks to the head and extrapolate because of: sparring, grappling, and takedowns) takedowns naturally increasing dictates the injury risk and rate. the risk of head injury, concussion • lack of pediatric and adolescent Very few catastrophic injuries are rates are not well accounted for study populations; reported.11 in most martial arts studies. Using

Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS mostly tournament medical reports when landing on bony prominences week of time lost from training. 18 (no postinjury data or follow-up) as a result of punches and kicks Another study showed a threefold and retrospective information, that miss their target. 2 Free-style increased risk of injury and a higher current studies may not accurately sparring (more common in younger risk of multiple injuries in taekwondo capture concussion injury rates. athletes) accounts for fewer injuries compared with karate.13 Of 5 martial Many studies do not count technical than prearranged sparring. 15 The arts disciplines (Shotokan karate, knockouts (TKOs) as concussive head head and face sustain injury resulting Aikido, taekwondo, kung fu, and injuries. More research with better from kicking and punching, including tai chi), taekwondo had the highest epidemiologic data and methods is epistaxis. 11 Simultaneous executed number of injuries requiring time off necessary in this field. punches are associated with karate from training (59%). 14 injuries. Taekwondo has a high relative KARATE Other reported karate injuries to incidence of lower extremity injury adolescents and adults include compared with upper extremity Defi nition a blinding choroidal rupture, 22 a injury because 80% of its competitive 23 13 Karate is a stand-up and striking unilateral adrenal gland hematoma, moves involve powerful, fast kicks. 24 martial art that started in Okinawa, a femoral osteochondral fracture, Mechanisms for injury include being 2 Japan. The basic goal is self-defense and a traumatic pseudoaneurysm of kicked, falling, and kicking. Kicks 25 by using punches, kicks, knees, the femoral artery. to the head and face are legal and elbows, and open hands to block serve as point-scoring techniques in full-contact taekwondo. 10, 18 Some an opponent’s strikes and then to TAEKWONDO disable the opponent with quick protective equipment is used but not strikes. 8 When takedowns are Defi nition always hand or foot padding. Being kicked, specifically by roundhouse executed, they tend to be used to set Taekwondo is a martial art and up finishing strikes. Weapons are kicks, may cause the largest number combat sport originating in Korea. of injuries.2, 11, 18 used in most styles of karate. The name taekwondo loosely Common injuries sustained in Injury Risk translates into “the way of the hand and fist” and involves 80% taekwondo include sprains/ Because much karate practiced in kicks and 20% hand techniques. 8 strains, fractures, and contusions/ 2, 11,18, 26 the United States is noncontact in Training involves a system of blocks, abrasions. Lower extremity nature, injury rates are lower and punches, and open-hand strikes injuries, especially of the foot, occur 2, 11–13,18, 27 usually less severe than in other and may include various takedowns frequently. Taekwondo martial art forms. In a study of or sweeps, throws, and joint locks, participants had higher rates of karate participants younger than 18 although it does not emphasize bruising and soft tissue injury years, a reported injury risk over grappling. Sparring allows kicks to compared with karate athletes in 1 13 a 12-month time period of 5.6 per the head and requires use of soft study. Head injuries are commonly 15 11,26 100 athletes was identified. One head and body gear. seen. One adult study found that study reported a 30% rate of injury 82% of training injuries sustained during 1 year of regular noncontact Injury Risk in the preceding 12 months were karate training. Karate focusing on Taekwondo uses contact aspects mostly soft tissue injuries to the technique just short of contact has of punching and kicking, which is lower leg or foot; however, 1 in 20 10 been shown to have a lower injury reflected in injury rates. Because of injuries were to the head, whereas risk compared with the contact kicks the various study methods, ages of another adult study supported the 14 of taekwondo. study participants, and methods of idea that more than 50% of adult The most common injuries reporting, as highlighted previously, injuries sustained in tournaments 26 sustained in karate include sprains/ reported injury rates for all ages occurred to the head and neck area. strains, contusions/abrasions, range from 0.4 to 139.5 injures Although less frequent in overall and fractures. 1, 11, 12, 15 Karate per 1000 athletic exposures, number, upper extremity injuries injuries occur from being kicked including light- and full-contact in taekwondo may be more severe (contusions), from falling (fractures), tournaments, 2, 11, 16 spotlighting some compared with lower extremity 27 and from kicking (sprains).2, 15 of the variability, validation issues, injuries. Karate injuries commonly occur to and potential unreliability of various The incidence of concussion in the lower extremities from being martial arts research. In 1 study, adult taekwondo ranges from 4.6 to kicked. Kicking injuries in less 32% of taekwondo injuries (pediatric 50.2 per 1000 athletic exposures, experienced individuals may occur and adult) resulted in more than 1 potentially up to 4 times higher than

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 6 , December 2016 3 that in American football. 27, 28 One sustained a higher proportion of to be higher in beginners compared study of adult Olympic taekwondo shoulder/upper-arm injuries 2, 13 with professionals (13.5 vs 2.79 kicks, measured by a simulated and neck injuries compared with injuries per 1000 participants). 19 head target, reported that the karate or taekwondo athletes.2 However, another study reported most common kick impacts used Pediatric concussions were more higher injury rates in heavier weight in taekwondo had acceleration and prevalent in judo than karate. 2 Judo classes (except super heavyweight). 20 recorded impacts equivalent to or choking techniques can cause loss of Commonly reported adult injuries greater than documented concussive consciousness.30 include soft tissue trauma, fractures 28 injuries in American football. In judo, athletes are more likely to (higher in more experienced Taekwondo rule changes have be injured while being thrown or athletes), and sprains and strains awarded more points for kicks aimed flipped versus karate and taekwondo, (higher in less experienced 19 at the head, which may increase in which most injuries are sustained athletes). Epistaxis (a nonprotected 27 the risk of concussion. Ineffective by being kicked. 2, 16 Improperly area) was the most frequent injury blocking skills may be related to risk executed throws can injure both in 17- to 26-year-old competitors 20 of severe head injuries. the attacker (if he or she drops the in 1 study. Vertebral artery Other reported taekwondo injuries competitor onto himself or herself) dissection was reported in 34 include bilateral radial head or the defender (if he or she lands 1 kickboxer. fractures. 29 Catastrophic taekwondo incorrectly). 2 Falling is a common injuries have been reported, pediatric mechanism for injury including deaths from kicks, cardiac leading to fractures. Joint-locking MIXED MARTIAL ARTS issues, and unknown causes. 27 techniques, in which joints are locked in full extension and thus are less Defi nition able to absorb stress during falls MMA incorporates a variety of JUDO (raising the risk of dislocations, martial arts styles, from stand-up subluxation, and fractures), can cause Defi nition fighting, ground fighting, and injury. 30 Other reported injuries throwing or takedowns, in which an Judo originated in Japan with sustained in judo include vertebral opponent is forced from an upright an emphasis on throwing or artery dissection, 31 embolic stroke, 32 or standing position into a grounded taking opponents down by and Paget-Schroetter syndrome 8 or more vulnerable position. using their energy against them. (effort thrombosis of upper Competitive bouts involve 3 to 5 Although striking is allowed in extremity). 33 form work, it is not allowed in rounds of fighting, each lasting 3 to sparring. Judo starts with a 5 minutes. Contestants usually wear standing phase and then moves MUAY THAI KICKBOXING small gloves with exposed fingers after a throw or takedown to the and are barefoot. The goal of an MMA ground phase, in which opponents Defi nition contestant is to defeat an opponent are immobilized and submission Muay Thai kickboxing originated in by: holds may be used. Thailand and is a close combat style • submission hold (joint lock or of martial arts that uses kicking, chokehold designed to make an Injury Risk punching (with boxing gloves), opponent give up or risk injury/ Judo uses takedowns, throws, and sparring, and kick blocks. 2 Knee become unconscious); flips, which use more of the upper blows to the head or to the genital extremities than other martial arts, area are allowed in regular Muay • frank submission, in which an such as karate and taekwondo. Thai kickboxing, but modified opponent gives up either by Strains/sprains, contusions, and competitive bouts prohibit any knee tapping out (tapping hand or other fractures are the most common blows to the head. body part on ground to signal 2, 11,16 injury. Upper extremity intent not to continue) or verbal Injury Risk injuries to the shoulder, hand, wrist, indication (opponent unable to 2,11 and fingers are common. Muay Thai kickboxing, performed continue or declares stoppage of Upper extremity injuries are more with different levels of protective match); common in judo versus the lower equipment depending on the level, extremity injuries seen more allows punches and kicks with • knockout or TKO (referee stops commonly in taekwondo and karate. 2 knees and elbows specific for this match, judging that an opponent is Hyperextension injury to joints discipline. 20 Limited studies exist unable to logically or safely defend may occur. 11 Youth judo athletes of this discipline. Injury rates tend himself or herself35, 36); or

Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS • judge’s decision at the end of the suggesting a concussion rate of 48.3 taught to fight from the supine match. 36 per 1000 athletic exposures in 1 position. Jiu-jitsu fighters look to take study. 36 Video analysis reported that their opponents to the ground and Injury Risk the rate of match-ending head trauma then attempt to place submission was 15.9 per 100 athletic exposures holds, often using arm bars, throws, With no reported pediatric injury (31.9% of matches). 41 All knockouts joint locks, and takedowns. 8 studies in the literature regarding were attributable to direct head MMA, all documented injury trauma, with 53.9% being strikes Pankration information is from professional to the mandibular region. In the 30 Pankration has origins in the ancient adult matches. Overall risk of injury seconds before match stoppage, Olympic Games, and modern versions has been reported as 85.1 to 228.7 losers sustained an average of 18.5 emphasize grappling as well as per 1000 athletic exposures, 37 – 39 strikes, with 92.3% of them to the limited-contact and full-contact much higher than that reported in head. Cervical injury biomechanics competitions. Class C (or grappling) other contact sports, such as from 4 common MMA takedown competition can be performed by collegiate football (8.1 per 1000 moves revealed biomechanics similar all age groups with takedowns, athletic exposures). 40 In a 5-year to being involved in a rear-end motor ground control, and submissions review of sanctioned adult MMA vehicle impact causing cervical spine allowed, but matches cannot be won fights, the injury risk over the injury.42 by brutality or deliberate intent to reported 5 years was 23.6 per 100 cause injury. Class B (or limited- fight participants.38 Age, weight, and fight experience did not statistically increase the injury contact) competition also can be Lacerations, abrasions, and altered risk in 1 study, 38 but the rate of injury performed by all age groups and mental state are reported as the was 2 times higher in amateurs than allows takedowns, ground control, most common injuries, 21 but another professional fighters in another submissions, and body strikes; study reported lacerations and study. 21 A losing fighter was 2.53 strikes above the collarbone are upper-limb injuries (likely resulting times more likely to be injured than a not allowed. Participants wear soft from striking) as the most common winning fighter. 38 gloves, helmets, and mouthguards. injuries. 38 One study reported Head strikes are allowed in class A injuries, in decreasing frequency, as Omohyoid muscle syndrome (full-contact) competition, which is 43 head injuries, lacerations, fractures, (insidious lateral neck protrusion) limited to participants 18 years and 44 and concussion. 37 and vertebral artery dissection older. 45 have been reported in athletes Because of the nature of MMA, head participating in MMA. and neck injury is a concern. Many INJURY-REDUCTION OR -PREVENTION athletes who experience TKOs TECHNIQUES receive subsequent injuries from OTHER MARTIAL ARTS FORMS striking the floor with their head. 36 Headgear and Mouthguards Definitions of what constitutes a Kung Fu With many martial arts disciplines concussion vary, and studies often Developed in China, kung fu is having participants deliberately miss trackable injuries, making primarily a striking form of martial target an opponent’s face with strikes 36 extrapolation difficult. arts that uses low stances and and kicks, protective equipment such 8 A recent study found that head powerful blocks with both open as mouthguards, eye/face protection, injuries accounted for 67% to 78% and closed fists to defend against and soft headgear has been used of total injuries in MMA. 37 In 1 study, attackers. Some styles may allow to reduce the risk of head or facial the severe concussion rate was throws and joint locks. Kung fu trauma. There is a paucity of studies reported as 15.4 per 1000 athletic has both “hard” (meeting force documenting injury risk reduction in exposures (3% of all matches); with force) and “soft” (using an martial arts that use these protective however, only official ringside aggressor’s strength against him or devices. injuries documented by the ringside her) techniques. Kung fu is widely The use of soft or other protective physician were reported, with no known for its beautiful and flowing headgear is intended to prevent follow-up evaluations provided. 38 In forms. or reduce the incidence of head this study, 33.7% of matches ended injuries, such as facial/scalp trauma Brazilian Jiu-Jitsu by TKO, despite the small number and activity-related concussions. of concussions reported. Blunt Brazilian jiu-jitsu is a martial art Although the use of padded force to the head resulted in the based on a unique form of ground headgear probably helps to prevent highest number of match stoppages, fighting in which participants are minor abrasions, lacerations, and

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 6 , December 2016 5 contusions, 46 there is little evidence protection. 46 Currently, few martial throwing techniques. Implementation to support this contention. There arts participants wear this type of of the new rules significantly is also a lack of data suggesting protection, and some may regard lowered the relative risk of injury that the use of padded or other the equipment as a nuisance or for competitors younger than 18 protective headgear can prevent or impairment to their vision or years (male and female), as well as a reduce the consequences of martial breathing. There are no published significant overall decrease in head arts–related concussions. Sport- studies evaluating the use of eye injuries; however, an increase in leg related concussions are often the protection in the martial arts. injuries was also established. 17 result of acceleration/deceleration and rotational forces placed on the Body Padding Training Changes 47 head and neck region. Although Several of the combat-oriented One study involving video analysis of unproven, there is also the potential martial arts disciplines use soft head blows leading to concussion in that protective headgear in other padding for arms, chest, abdominal, competitive taekwondo participants sports may actually confer a higher groin, and leg regions. 46 The padding found that close proximity between risk of concussion because of a worn by taekwondo athletes may athletes and reception of a single potentially perceived false sense of offer some protection, but this roundhouse kick were common security for participants, parents, and protection may be of greatest benefit mechanisms of injury. 50 Another instructors. to the athlete executing the kick study found that young age and lack rather than to the recipient of the Mouthguards have been shown of blocking skills were risk factors technique. 14 Although, in theory, to reduce the incidence of dental for concussion in taekwondo. 51 these devices may reduce skin trauma and other direct oral/facial Development of blocking skills, safety trauma and muscle contusions, there injuries in other combat sports, education, and rigorous enforcement 48 are no data on their efficacy in the such as boxing ; however, no solid of the competition rules were among practice of martial arts. evidence exists in the martial arts the suggestions made to reduce or in any other type of sport or risk of concussions in competitive Rule Changes activity that suggests a reduction in taekwondo. 50, 51 concussion incidence or severity with Although some studies have identified mouthguard use. predisposing factors for injury that Monitoring the number of martial At the time of this writing, it cannot include male sex, exposure to sparring arts training hours per week may be recommended with any level and competition, and less experience, play a role in reducing injuries. One of certainty that use of any type of rule changes that limit sparring in the study did not find multiple injuries protective headgear or mouthguard latter group may have the greatest or injuries requiring time away can reduce the risk of concussions effect on injury reduction.49 However, from activity in martial arts athletes during sparring or competitive other studies have found lower younger than 18 years who trained martial arts participation. In addition, injury risks among less experienced less than 3 hours per week. Injury no protective device worn during youths, possibly because of less risk doubled with each additional MMA competitions can mitigate technical ability, lower body mass and 2 hours of training after the first 3 the potentially serious effects of strength, and an inability to generate hours, although no major injuries 14 chokeholds leading to near- or the same level of force than older, were reported. full suffocation, which could cause more experienced martial artists.14 anoxic brain injury, cervical spine Therefore, the exact role of rule Concussion Recognition and Safety changes limiting sparring remains damage, or even vertebral artery Although protective safety equipment uncertain. injury, leading to cerebral vascular may not protect against or prevent accidents. Additional research is Appropriate rule creation and concussions, proper recognition, needed to determine whether these enforcement have been shown to evaluation, management, and return theoretical concerns are encountered reduce injury risk. In 2000, the World to play of athletes with suspected and in young MMA participants and, if so, Karate Federation adopted new documented concussion injuries is at what rates and levels of severity. rules regarding prohibited behavior, important. All head injuries should Many martial arts equipment including excessive force used in be evaluated, clearly documented, companies manufacture clear dealing blows to permitted areas, to and managed by a pediatrician or plastic face guards or padded metal forbidden areas (throat, arms, legs, health care provider trained in grilles that integrate into standard groin, joints, and instep), and to the the evaluation and management sparring headgear and do provide face with open-hand techniques of pediatric concussions. Athletes a significant level of eye and face as well as dangerous or prohibited recovering from a concussion should

Downloaded from www.aappublications.org/news by guest on September 28, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS follow normal return-to-learn and 2. Children and adolescents should 6. Pediatric health care providers return-to-play guidelines previously only participate in martial should encourage the teaching established and considered standard arts classes or competitions of improved defensive blocking for concussion management. 47, 52 supervised by instructors with techniques to reduce the risk of appropriate training regarding dangerous blows to the head. proper teaching of the particular 7. Pediatric health care providers activity and understanding MEDIA INFLUENCE, PERCEPTION, AND should support the institution of a child’s limitations based RELATION TO YOUTH PARTICIPATION of rule changes that eliminate on age, maturity, stature, IN MMA blows to the head and conversely and experience. Martial arts any points awarded for kicks or Professional MMA has become a competition and contact-based blows to the head to reduce the sports culture sensationalized by the training should be delayed until risk of concussions in martial media. Primetime, televised showcases children and adolescents have arts. promote MMA as spectator events, not demonstrated adequate physical unlike some other American sports, and emotional maturity during 8. Anticipatory guidance regarding with financial incentives for both noncontact preparation and have injury risks of particular martial participants and sponsors. MMA draws demonstrated competency with arts disciplines, along with attention as entertainment venues for noncontact forms, movements, proven and unproven benefits many. Dreams of “making it big,” and techniques. of protective equipment, are encouraged as part of a large paychecks, and future wealth 3. In discussing selection of various preparticipation evaluation appeal to many parents and children. disciplines and subtypes of by the pediatric health care In emulating what they see in the adult the martial arts, the pediatric provider. MMA culture, children are at risk for health care provider can imitating professional MMA moves help to discriminate between 9. Although some evidence exists and techniques seen in mass media noncontact forms, which have a that training >3 hours per week (eg, choking out, repetitive head blows relatively low risk of injury, and may increase injury risk, the to floor), even though these moves sparring or contact forms, which relation of hours of training per may not be sanctioned for their ages. confer a higher risk of injury. week to particular martial arts Evidence also shows that exposure to injury risk requires more study. media violence can increase aggressive 4. For those martial arts behavior and desensitization to disciplines that involve sparring, 10. The nature of MMA combat violence.53 Children may try to rigorous enforcement of fighting, which includes rapid perform risky moves learned from rules prohibiting excessive thrusts of the head to the floor mass media exposure in practice or force, dangerous movements, and chokeholds to place an in settings with minimal or no adult or blows to forbidden areas opponent into submission, supervision. As advocates of young should be encouraged, with confers a high risk of concussion, athletes, pediatricians and pediatric safety education promoted for asphyxia, or other head and health care providers can educate all instructors, officials, and neck injury. As a result, child parents, families, coaches, teachers, participants. Instructors and or adolescent participation in and community leaders with facts on officials are encouraged to have MMA bouts that involve these the increased susceptibility to injury an appropriate understanding techniques should be strongly if children are imitating what they of the rules and safety discouraged. As advocates of see from excessive media exposure of qualifications. young athletes, pediatric health MMA contests. 5. Although many martial arts care providers can educate disciplines require the use of parents, families, coaches, soft protective headgear, there teachers, and community leaders with facts on the increased PRACTICAL CONCLUSIONS ON MARTIAL is no evidence that such devices susceptibility to injury if children ARTS PARTICIPATION FOR THE reduce the risk of concussion. It PEDIATRIC PROVIDER is encouraged that participants are imitating what they see from and families also be counseled excessive media exposure of 1. As a sport or activity, martial against engaging in more MMA contests. arts can provide children and aggressive activities under the adolescents with vigorous levels misconception that wearing LEAD AUTHORS of physical exercise that can lead headgear ensures increased Rebecca A. Demorest, MD, FAAP to better overall physical fitness. protection against concussion. Chris Koutures, MD, FAAP

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