The Effects of Repeated Head Trauma and Multiple Concussions

Sidney Crosby was out again – shouldn’t we worry about his long term health?

Everyone is talking about concussion in sport but there have been few people in the media who have raised awareness regarding a particular medical condition like Sidney Crosby has for concussions: the effects of repeated head trauma and multiple concussions.  Concussions have been a part of contact sports for as long as these sports have been around. The face of the National Hockey league went down with a concussion that took him out of play for more than an entire season and then another concussion caused him to miss several more games at the beginning of the 16/17 season.  He scared everyone yet again in the 2017 playoffs and the world should be asking: what effect this will have on his long term health?

Research and awareness for the study of concussions in sports has increased significantly in recent years but our overall understanding of primary (first) let alone multiple concussions is still relatively limited.  It is the brain that we are dealing with after all.  It’s a bit like trying to solve an error in the most complex super computer in the world without the option of trying the typical restarting the computer trick.  Sid has unfortunately suffered multiple concussions. This once again shines a spotlight on concussions in sports and in particular on one of the larger areas of concussion study in recent years:  the circumstances surrounding the effects of repeated head trauma and multiple concussions on the brain and just as important, the eventual long term outcomes of such traumas.

There are a couple of areas for concern when we look at the circumstances of repeated head trauma.

Second Impact Syndrome (SIS)

The first is a condition called second impact syndrome (SIS).  This is a circumstance when a second head injury is sustained when the symptoms of the fist head injury have not yet resolved.  This condition is generally associated with catastrophic outcomes such as cerebral edema (brain swelling) and herniation often resulting in sudden death.  This is a relatively rare occurrence but one that is still considered in the careful management of athletes following a concussion.

Repetitive Head Injury Syndrome

In circumstances where the initial concussion has fully resolved and then a second concussion is sustained, such as in the case of Sidney Crosby, a different term called repetitive head injury syndrome has been used.  In these cases catastrophic outcomes are not observed but the recovery time-lines, cognitive deficits and propensity for additional concussions seems to be significantly worse than in first time concussions.  This has been evident in the premature ending of several hockey player’s careers as a result of multiple concussions such as Pat Lafontaine, Scott Stevens and Eric Lindros among many others.

Even with careful management of first time concussions it is evident that the risks and dangers associated with impacts to the head rises substantially once an athlete has sustained a primary concussion.

What about Chronic Traumatic Encephalopathy (CTE)?

Repeated head trauma has also been linked with a condition called chronic traumatic encephalopathy (CTE).  This is a progressive degenerative disease of the brain thought to be a direct result of repeated blows to the head and resulting in cognitive impairments similar to Alzheimer’s disease.  There is also evidence available that indicates a higher incidence of depression in athletes that have sustained  multiple concussions.

To add to the complexity of these cases even further, it is not uncommon for secondary conditions to also exist such as traumatic injuries to the vestibular apparatus (balance center) in the inner ear or upper neck injuries.  These conditions can significantly affect the severity of the symptoms and rate of recovery from primary or repeated concussions and usually require specific rehabilitation in order for successful functional recovery to occur.

And the Pattern Keeps Repeating

As the size and speed of athletes continues to grow with advances in dietary and training programs, technologies and the odd performance enhancing supplements (we won’t pretend this doesn’t exist) so too do the forces involved in the games we play.  The skull’s tolerance for these forces unfortunately has not advanced along with these other factors and therefore the prevalence for traumatic injury to the brain may be destined to rise further as time progresses. Sadly, rule changes and attempts to curb concussions will not stop them from happening.

The importance of further study of the effects of trauma to the brain and more importantly the management and prevention of such incidents will be of the utmost importance to the safety of our athletes in the future.  There are many models for determining timelines for return to sport following concussions but little consensus and hard evidence at this time to guide this process as it can vary significantly from case to case.  It is naive to think that we can expect to have injury to something as complex as the brain present as a consistent and predictable pattern of symptoms, signs and recovery timelines.

Professional examination and ongoing treatment and monitoring of the condition is paramount for successful management of these complex cases.  Individual planning and progression of a return to sport or activity program must be developed and carefully monitored by a trained professional in order to minimize further risks of repeated head trauma and the subsequent conditions associated with repetitive head injuries.

It will be interesting to watch the effects of the repeated head injuries sustained by Mr. Crosby over the coming years given the evidence available  regarding multiple concussions.  As a hockey fan I truly hope that he is able to continue on to a long and successful career without suffering the consequences of long term negative effects later in life.  I guess only time will tell for now and we can only wish him a long and healthy post hockey life.

With thanks to Tayler Gray for his major contributions to this article,

In health, Grant Fedoruk