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Chronic traumatic encephalopathy in sports
Martland coined the term "punch drunk condition" to first describe chronic traumatic encephalopathy (CTE) in 1928. After years of fighting, professional boxers began to demonstrate memory problems, mood swings, and behavioral changes. Martland theorized that the cognitive and behavioral problems found in boxing competitors were caused by sub-lethal repeated head strikes received during the fighters' careers. There is also a growing consensus that CTE can develop in players from other sports as a result of repeated head trauma. The most common cause of chronic traumatic encephalopathy (CTE) is contact sports, such as mixed martial arts, American football, boxing, ice hockey, rugby union, and rugby league. It is unknown what the exact amount of trauma required is for CTE to occur.

CTE is characterized by a constellation of symptoms induced by lesions in the pyramidal, extrapyramidal, and cerebellar systems. CTE's cognitive and behavioral symptoms reflect the areas of the brain that have been pathologically proven to be the most impacted by the disease. Learning and memory deficits are the most common early cognitive signs. Depression, apathy, agitation, and suicidal ideation are all indicators of the associated changes in mood. Poor impulse control and increasing hostility are examples of behavioral disturbances associated with CTE. Dementia would develop 10 to 20 years after retirement from the ring in boxers with advanced stage CTE. Dysarthria, which is accompanied by gait ataxia in 90% of instances, is another motor clinical symptom of CTE. Persistent headaches were also a common complaint among patients. Although some CTE patients may have a fine tremor on occasion, extrapyramidal symptoms are typically uncommon. Memory, information processing and speed, finger tapping speed, attention and concentration, sequencing abilities, and frontal executive functions such as planning, organization, reasoning, and judgment have all been found to be impaired during neuropsychological testing in former boxers suspected of having CTE.

Chronic Traumatic Encephalopathy in Mixed Martial Arts
In recent years, mixed martial arts (MMA) has been closely investigated by several medical organizations, which have expressed concerns about the sport's safety due to frequent head damage among competitors, with some calling for the sport to be outright prohibited. Through the dearth of media reportage, MMA fighters are demonstrating concern as they grow more aware of the dangers of the sport. Gary Goodridge, an MMA professional fighter, was the first to be diagnosed with CTE in 2012. MMA is a full-contact, unrestricted fighting sport that combines unarmed Oriental martial arts (such as judo, muay Thai, karate, and jiu-jitsu) with Western fighting skills (e.g., Greco-Roman wrestling, kickboxing, boxing). Two contenders, both wearing minimum protective gear, use a variety of striking and grappling methods against their opponent, both on the ground and standing. A competitor wins by concussing an opponent into a vulnerable position (knockout (KO)), inducing syncope through a neck choke, disabling an opponent through joint dislocation, subluxation, or soft tissue injuries, or coercing an opponent into submission through any combination of the above. When a participant is unable to properly defend oneself, which leaves them completely defenseless, a technical knockout (TKO) occurs.

History
MMA is a relatively new sport compared to other forms of martial arts, having initially started in the 1980s. MMA tournaments were first launched in the United States (US) in 1993 with the Ultimate Fighting Championship (UFC). It was named merciless as there were no regulations, no time limitations, no weight classifications, and minimal restrictions. MMA was briefly outlawed in the United States in the mid-1990s, following widespread condemnation from lawmakers concerned about the sport's safety, with then-US Senator John McCain referring to it as "human cockfighting ." Following that, the "Unified Rules," which established a list of forbidden activities (such as genital attacks, biting, throat attacks, and head butting) to safeguard the safety of players was introduced. Most international MMA contests followed suit and adopted these regulations. MMA is growing in popularity among the general public globally as a result of greater media coverage. With more amateurs taking up the sport, MMA clubs are developing at a rapid pace. Participants in this sport must be aware of the potential health risks that MMA poses. Furthermore, there is currently no definitive pharmaceutical treatment for CTE, although animal studies have suggested that anti-dementia medicines such as memantine may be advantageous.

CTE Case Study
A 40-year-old Caucasian male with adulthood-onset epilepsy presented to a clinic in May 2010 after a year of impaired memory and poor attention. Short-term memory loss, word-finding difficulty, slower processing speed, and difficulties organizing and multitasking were all symptoms of his growing cognitive decline. His mood had not changed, and he exhibited no symptoms of depression or anxiety. He was a university graduate with no previous history of addiction or family history of dementia. He had been practicing MMA for almost ten years. He served in the United States Marine Corps before working for five years as an MMA school manager and coach. In his martial arts training and work, he suffered from recurrent minor head traumas and transient asphyxiation events. He had hand tremors, fine motor incoordination, and lower limb ataxia on physical examination. No abnormalities were detected on laboratory tests, lumbar puncture, and electroencephalography. However, magnetic resonance imaging of the brain revealed minor asymmetry in the parahippocampus regions of his brain, including a smaller left hippocampus and dilatation of the left temporal horn. Except for timed working memory tasks, a neuropsychological evaluation undertaken in 2010 revealed above-average performance on most cognitive domains. He had been an English instructor, teaching his native language, since September 2010. He was unable to continue working two years later due to severe memory and organization difficulties. He was also described as being more irritable, fatigable, and distractible. To improve his attention, he was given methylphenidate (60 mg per day). He developed benzodiazepine addiction but was able to effectively detox. In 2013, neuropsychological testing revealed deterioration in most cognitive domains, including severe declines in auditory and visual attention and memory, as well as further declines in executive function. CTE was suspected based on clinical and cognitive symptoms. Memantine was added to his treatment plan, and he was continuing to be monitored in the clinic. He continued to cognitively decline and was eventually lost to follow-up.

Research
Research has shown that head injuries accounted for the largest distribution of injuries by anatomic location in the epidemiology of MMA injuries, with statistics ranging from 67.5 percent to 79.4 percent. Studies have shown that in contrast to other fighting sports such as judo or taekwondo, where head strikes are prohibited, the damage pattern in MMA was remarkably comparable to that of professional boxing. Video analysis of 844 televised UFC MMA bouts indicated that repetitive blows were responsible for over 90% of TKOs. When the TKOs caused by repetitive hits were investigated further, the defeated fighter was hit by a sequence of multiple strikes to the head that escalated in frequency in the 30 seconds before the contest was finished. Choking and neck grappling, which are widespread in MMA, can cause persistent intermittent hypoxia, which can lead to neuronal dysfunction due to a reduction in cerebral tissue oxygenation. Assault on a young brain, which is still developing and more sensitive to harm, has long been thought to have more disastrous implications for cognitive health later in life. When young athletes are subjected to mild closed-head impact injuries, there is accumulating evidence that there are consequent cellular changes in the brain. In a 2018 study, astrocytosis, phosphorylated tau protein pathology, microvascular injury, myelinated axonopathy, and perivascular inflammation were discovered in the post-mortem examination of four adolescent athletes that died in the acute-subacute period between 1 day and 4 months after suffering sports-related close impact head injuries. In comparison, four teenage controls that passed away from other medical causes did not demonstrate these changes in their post-mortem analysis. The researchers conducted trials on unanaesthetized mice to further corroborate their claim that closed-head impact damage triggers early CTE brain abnormalities. They developed equipment that enabled a confined mouse to receive a single non-lethal lateral blow to the head in the temporal-zygomatic region and compared the results to control mice. They discovered that the mice sustained only minor or no acute brain damage as a result of the impact. The scientists next performed post-mortem analyses at various time intervals following the impact on the brains of mice that had been subjected to a lateral head hit. They found areas of resolving astrocyte and microgliosis, diminished neuronal density, and clusters of perivascular hemosiderin-laden macrophages by two weeks post initial injury. They also discovered perivascular aggregation of phosphorylated tau proteins in the brains of mice that received the lateral hit, which is characteristic of CTE.

Prevention
Because there are currently no definitive treatment options for CTE after it has developed, prevention is critical. To date, the benefits of drugs such as acetylcholine esterase inhibitors, NMDA receptor antagonists, stimulants, or neurorehabilitation are inconclusive. Thus, it's critical to discuss how we can protect MMA fighters from developing CTE. Some prevention techniques include briefly pausing the fight whenever a competitor is knocked down to permit the identification and evaluation of traumatic brain injury. Referees should also be educated to recognize defenseless opponents or those who have lost consciousness and to quickly halt the fight. Finally, following a TKO or KO, medical personnel should be there to assess the athlete, and medical suspensions should be enforced by the relevant athletic commission to allow for adequate healing time before the next contest. The only way to avoid CTE is to avoid sustaining repeated head injuries. While many head injuries are difficult to foresee or avoid, some steps can be taken to reduce risk. This includes seeking appropriate medical attention after injury and making it compulsory to wear necessary protective equipment.

Diagnosis
There is currently no test that can be used to diagnose CTE. A diagnosis is made based on a history of contact sports participation, symptoms, and clinical findings. Evidence of degeneration of brain tissue and deposits of tau and other proteins in the brain, which can only be observed after death, are required for a diagnosis (autopsy). Some researchers are working hard to develop a CTE test that may be utilized while patients are still living. To diagnose CTE, researchers hope to ultimately use a variety of neuropsychological tests, biomarkers, and brain imaging such as specialized MRI tests. Imaging of amyloid and tau proteins, in particular, will aid in diagnosis.

Management
CTE is difficult to cure because it can only be detected after a person has died. Furthermore, no treatment technique has been proven to improve long-term prognosis. Symptoms can be treated empirically if necessary. People with CTE symptoms may receive the following treatments : - Mood swings can be treated with behavioral therapy. - To reduce discomfort, pain management therapy is used, which includes medications, massage, and acupuncture. - Exercises can be used to improve memory and recall ability - People who learn to cope with the symptoms of CTE often report a higher quality of life, with less pain, better memory, and fewer mood swings. Chronic Traumatic Encephalopathy in Mixed Martial Arts compared to other sports American Football Researchers gathered the autopsied brains of 202 former football players that donated their brains to research. This included a variety of players including those who had previously played in the NFL, along with through college, and a handful who had only played high school football. CTE was found in 177 of the 202 brains, accounting for over 90% of the total. There was also a pattern noted: those who had played football for a longer duration had higher rates of brain injury. CTE was found in 99 percent of the former NFL players in the study. This shows that brain trauma has a cumulative effect that increases the risk of CTE. The more trauma that is experienced over time, the worse the symptoms become. On September 30, 2014, Boston University researchers reported that 76 of 79 brain autopsies of former NFL players tested positive for CTE. That figure had increased to 90 out of 94 as of January 2017. In July 2017, CTE was discovered in 110 of 111 former NFL players whose brains were autopsied, according to a study published in The Journal of the American Medical Association. Thus far, only two MMA fighters have tested positive for CTE, Jordan Parsons (killed by a drunk driver in 2016) and Tim Hague (died from a traumatic brain injury from a boxing match in 2017). There are likely more MMA fighters with CTE who have not been diagnosed yet, as the diagnosis cannot be confirmed prior to autopsy.

Boxing
CTE is a condition that can affect both amateur and professional boxers. Although 17 % of professional boxers in Britain with careers in the 1930s-50s had clinical evidence of CTE, no current epidemiological research exists to evaluate the prevalence of this disorder in modern-day boxing. It is estimated that approximately 20% of boxers have CTE.

Hockey
CTE prevalence rates among hockey players have been reported to range from 50% to 99%. Swab et al. (2021) discovered that 6 of 11 (54.5%) hockey players had CTE in a post-mortem investigation.