Exploratory study on illegal pharmacologic agents in mixed martial arts performance

Mixed Martial Arts (MMA) is a combat sport that requires maximum physical effort during competitions. In this context, some athletes can use illicit substances in order to improve their performance. By means of paired analysis, the present study compared the motor actions of athletes who had failed an anti-doping test versus their performance in combat against a winner or loser without doping presence. For this, 267 rounds (male and female) were analyzed in professional matches. The rounds were paired by athletes in the conditions: doping, winning and losing. Motor actions were analyzed through a specific and previously-validated protocol. Of the substances detected, anabolic androgenic steroids represented 55% (p≤0.001). Doped athletes had lower pause time (83.4±68.3 vs. 131.7±95.2, p≤0.001) and longer time at high-intensity (85.2±86.6 vs. 51.2±73.3, p=0.002) compared to the losing condition. Regarding the technical-tactical analysis in standing combat, winning presented a higher mean compared to doping in all variables except for Knockdowns (p=0.08), single body strikes landed (p=0.15), single leg strikes landed (p=0.25) and single strike attempts (p=0.4). In conclusion, athletes who tested positive presented higher performance in the physical variables (effort and pause time) in comparison to the losing condition; however, doping did not reflect in better technical-tactical performance.


INTRODUCTION
Mixed Martial Arts (MMA) combines techniques of different combat sports, such as: boxing, kickboxing, muay thai, wrestling, judo and Brazilian Jiu Jitsu, including motor actions in striking and grappling movements 1 . MMA Fights are composed of three to five rounds lasting 5' with 1' intervals, where winning is achieved by knockout, technical knockout, submission or judge's decision [1][2] . The analysis and diagnosis of technicaltactical performance in MMA can be performed through videos, providing feedback to improve performance [2][3][4] , allowing the coach to develop a higher variety of strategies which interfere in the choice and the frequency of actions taken during combat [5][6] .
One way to understand how combat dynamics occur and to choose the best way to prepare athletes is through time-motion analysis (TMA). TMA has been applied in many combat sports and enables describing attempts of attack, defense and decisive actions in competitive performance [7][8][9][10] . This information can be used in inferences about the intensity and energy demands used in combat 7 . In fact, when MMA athletes are consistently training at high intensity and there is no control of training load, their of injury risk increases [1][2][3][4][5][6][7][8][9][10][11] , affecting their competitive performance.
Regarding the neuromuscular component, strength and power are essential for competitive success in combat sports 1-11-12 . In this sense, many athletes use ergogenic substances as a way to improve performance and chances of winning, but some of those substances are considered doping 13 . According to Henne 14 , professional combat sports competitions in the United States such as Boxing and MMA partially follow the WADA (World Anti-doping Agency) code, but not all guidelines are employed. The lack of wide control over doping may encourage athletes to use illegal substances. In a study with kickboxing athletes, Sekulic et al. 15 found that the behavior associated with using a doping substance increases when athletes perceive that doped fighters are not caught by the test. However, the equality of conditions and fair play should be the pillars of the sport, and doping rules are necessary for fair competition 16 .
The International Olympic Committee (IOC) defines doping as the administration of any exogenous substance in abnormal quantity with the intention of artificially and unfairly improving performance [16][17] . Although illegal substances such as anabolic androgenic steroids (AAS) increase strength and endurance, and also reduce fatigue 16 , the harmful effects of these substances on the health of an athlete is proven in their hormonal and aesthetic appearance as well as by their behavior 18 . Considering that the use of doping is associated with an improvement in physical fitness, and possibly of the motor actions involved in MMA, it is essential to investigate if there are differences in the combat actions/performances of doped athletes, whether being winners or losers. However, to the best of our knowledge no has study investigated the effect of illegal substances in MMA performances. Thus, the present study compared performances in three conditions through a paired technical-tactical analysis: a) positive on the anti-doping test; b) winning; and/or c) losing without doping.

Study design
This is a comparative and descriptive study based on retrospective data of paired athletes in MMA who had failed an anti-doping test, and analyzed the following conditions: winning without doping vs. losing without doping vs. doping (regardless of outcome). This paper specifies the technical-tactical demands of a high-performance athlete and promotes new concepts in performance measurements related to the use of illegal substances. For this, a technical-tactical analysis protocol validated and identified in previous studies 2-3-19 was adopted. Data collection was conducted from events in the Ultimate Fighting Competition (UFC ® ), Pride ® , World Extreme Cagefight (WEC ® ), Elite Xtreme Combat (EliteXC ® ) and Strikeforce ® . All episodes take place in a climatized environment except for the Ibirapuera Arena (UFC 117) with temperatures between 24-27ºC. The present study was submitted to and approved by the Juiz de Fora University Research Ethics Committee (protocol 51979/2017), according to the rules of resolution 466/12 of the National Health Council. According to previous studies, the study was anonymous and confidential by replacing the personal identification of athletes 3-9-19 .

Sample
Fifty-four (54) athletes were included in this study. The sample was composed of 267 rounds in combat (both genders). For the inclusion criterion, athletes should have failed an anti-doping test. The rounds were paired by athlete, separated by the outcome: winning (n=90), losing (n=85) and doping (n=92). The sample was obtained from professional MMA events from 2001-2014. All evaluated athletes had prior experience with the rules and procedures used during the professional events, no intervention was performed, and the combat was maintained according to the official rules.
The following procedures were adopted for the sample composition: the investigators initially searched for all reported doping cases in the professional MMA leagues. Next, all the athletes who had tested positive were identified. Combat videos were located on the internet and personal archives; when the complete video was found, two more matches (winning and losing) of the same athlete were included with the following criteria: a) the match should be in the same weight division; and b) respect the maximum time of 6 months between matches. Cases that did not meet the criteria described above were excluded. Table 1 presents the events in which athletes tested positive, date, doping agent and the outcome.

Time-motion analysis protocol, intra-and inter-specialist validation
The technical-tactical actions and the spatio-temporal changes were ob- Continue… served by 5 researchers in agreement with the frequency of technical and tactical actions in standing and groundwork activity, as well as the moments of high-and low-intensity following a previously established protocol 3-9-19 . In order to ensure ecological validity and to confirm the elite status of the athletes, the matches were analyzed using professional-quality combat records. All videos included in the analysis were of sufficient quality (standard 480/60i definition) with panoramic view of the entire competition area. When appropriate and considering the inclusion criteria, athletes were evaluated in a single competition and evaluated more than once when multiple combination videos were available, following the previously published protocol 9-10-20

Data analysis
The Kolmogorov-Smirnov test was applied to verify the normal distribution of the data.

DISCUSSION
Anti-doping tests aim to prevent athletes from winning at any cost, thereby maintaining competitive fair play 16 . We do not know of any studies which have compared the performance of athletes with or without doping in MMA. This study conducted a primary analysis of the effect of doping on the performance of professional MMA athletes. The main results indicated that athletes who tested positive presented a higher performance in physical variables such as effort and pause time; however, the doping condition did not reflect better technical performance (Table 3 and 4), so the absence of differences in technical analysis possibly influenced the frequency of wins in doped athletes (Table 1). According to Henne 14 , although doping cases in other professional sports such as cycling receive increased media and academic impact, performance enhancing drugs have attracted the attention of boxing and MMA athletes.
From the total of detected cases, the majority was for AAS; in fact, the use of these substances tends to increase strength and muscle performance 16 . According to Hartgens et al. 21 , the use of AAS increases short term strength by 5-20%, body mass by 2-5 kg, and increases erythropoiesis. However, it is necessary to consider the lower number of experimental studies which measured the effect of AAS on athletic performance [13][14][15][16][17] . Baume et al. 22 did not observe improvement in mental and aerobic performance after multiple doses of AAS. On the other hand, our results showed a physical advantage for doped athletes, as they presented lower pause and higher time in high-intensity actions in comparison to the losing condition. However, a lower pause time does not necessarily reflect higher chances to win, since such physical fitness advantage may represent a higher volume of motor actions applied during combat, which becomes an advantage if the combat outcome is defined by the judge's decision. However, pause can be an advantage for an athlete who wishes to finish the match (i.e. by Knockout, technical knockout or submission). According to Amtmann et al. 7 , actions in low-intensity effort can be used for strategic development, in which the athlete will use this period for recovery and analyze the motor actions of their opponent.
It should be noted that doping did not result in better performance for any of the measured variables when compared with winning condition. Many factors may explain lower physical performance in doping vs. winning among the technical variables. The specific literature does not show improvement in technical ability when an athlete administers any type of doping, mainly with AAS, but studies do show that the level of anger and hostility increase 13-16-18-21-23 . The influence of AAS on mood affects the athlete''s technical ability, resulting in a lower accuracy of landed strikes (Table 3). In fact, the results of Miarka et al. 9 through logistic regression reveal that effective landed head strikes are the best way to increase the chances of winning in MMA.
Another factor that limits doping in improving combat sport performance is associated with the multifactorial aspect that determines the outcome in MMA 3-4 . Miarka et al. 4 found that winning had a higher frequency of strikes landed and submission attempts in comparison to losing athletes, especially in the third round. It is also worth noting that our analysis compared the same athletes in the three conditions; however, the opponent was not matched, so possibly the level of opponent in the winning condition is not the same as in losing and doping. This limitation must be considered when interpreting the results presented herein; on the other hand, it opens up a new investigative avenue for future studies. Another limitation of the present study is the heterogeneous analysis of the detected substances. There were 4 different categories, and some of which do not improve muscle power and strength such as opioids and diuretics [25][26] , therefore future studies should analyze each doping group separately by evaluating the effect on the performance, time and the amount used.
Finally, we emphasize that the present study is an introductory analysis on doping and MMA performance. We believe that the present work will result in future research protocols that can better elucidate the effect of these substances in a sport where many factors can determine the outcome. Our study did not show a competitive advantage and it should also be emphasized that adverse health effects can occur due to the use of doping agents such as AAS [14][15][16][17][18][19][20][21][22][23][24] . In this sense, educational campaigns can be effective, since doping may be involuntary through ingestion of contaminated supplements 24 . However, Sekulic et al. 15 observed that kickboxing athletes with a higher level of nutritional knowledge tend to be less influenced in doping use.

CONCLUSION
In view of the aims, applied methods, results and limitations, we conclude that doping results in better physical performance when compared to a losing condition. However, doping results in lower technical performance when compared to a winning condition.