Recognizing and Treating Concussions Related to Sports Injuries
The stories are heartbreaking. The young athlete who sustains a concussion while competing and needs intensive rehabilitation for cognitive, balance, sleep, and emotional symptoms—occasionally with long-term disability and pain. A concerted effort by the CDC, state and local governments, and advocacy groups around the country have drawn attention to the risk for traumatic brain injuries (TBIs) in sports. Early recognition, screening, and treatment have helped prevent more serious injuries in thousands of children.
Despite these efforts, however, TBIs remain an all too frequent occurrence. In the United States, between 1.7 and 3.8 million TBIs occur each year,1 with over 240,000 of these injuries occurring due to sports and recreational activities.2 Between 2001 to 2009, the number of sports-related TBIs seen in emergency departments (EDs) increased 62%, from 153,375 to 248,418; the highest rates are among males between 10 and 19 years of age, with 70% (173,285) of the TBIs occurring in this population.2 TBI was cited as a contributing factor in approximately 30% of all injury-related deaths—accounting for 52,000 deaths per year (see sidebar).
Concussion, referred to as commotion cerebris in European nations, is a subset of TBI that is defined as “a complex pathophysiological process affecting the brain, induced by biomechanical forces.”3 Typically, it is caused by a direct impact to the head but can occur as a result of any ‘impulsive’ force transmitted to the head.
Neurologic impairments such as headache, cognitive impairment, emotional symptoms, and behavioral changes rapidly occur and usually are short lived, but less frequently may evolve over a period of hours.3 Concussion is thought to be a functional disturbance and, thus, the results of imaging studies such as computed tomography (CT) scans usually are normal because these tests evaluate brain structure rather than function.3
Studies of the common symptoms that occur after a sport-related concussion (SRC) demonstrate that there is a natural grouping of symptoms, with 4 symptom clusters reported: sleep disturbance, headache, cognitive deficits (slow reaction time, feeling in a fog), and neuropsychiatric features (emotional aspects, irritability).4,5 These symptoms account for the great majority of morbidity after a SRC and provide clinicians with opportunities for intervention.
This article will focus on non-pharmacologic therapy of pain after a SRC, which is strongly recommended as the backbone of recovery, as well as several pharmacological interventions for symptom alleviation, which are not supported by strong evidence. These pharmacologic therapies should be used cautiously, with close consideration of individual risks and benefits by clinicians with experience managing patients with SRC.
It is widely accepted that the most important intervention in the management of SRC involves physical and cognitive rest until the acute symptoms have resolved. The majority of concussions (80%-90%) resolve in a short period (7-10 days), although the recovery timeframe may be longer in children and adolescents.3
Athletes who have suffered previous concussions are at a significantly higher risk for incurring a repeat concussion,6 especially in the acute post-concussive period. There may be a risk for “second-impact syndrome,” diffuse cerebral swelling with catastrophic deterioration, postulated to occur after repeated concussions, and particularly in adolescent males.7,8 Thus, concussed athletes should be removed from physical activities that may expose them to further risk for impact to the head.
Cognitive rest involves abstaining from activities requiring concentration and attention, such as schoolwork and video games. Due to a dearth of published literature assessing the appropriate duration of rest during recovery from SRC, current guidelines are largely based on consensus opinion employing a cautious approach, in which the patient gradually increases their levels of activity and eventually returns to sports. Typically, the initial period of rest after concussion should last at least 24 to 48 hours or until the resolution of acute symptoms.
Following this initial period of rest, athletes should follow a stepwise graduated return to play protocol. A 2012 consensus statement from the international Concussion in Sport Group (CISG) suggested the following steps in the graduated return to play protocol: 1) no activity, 2) light aerobic exercise, 3) sports-specific exercise, 4) non-contact training drills, 5) full-contact practice, and 6) return to play.3 It generally is recommended that athletes spend at least 24 hours in each step (overall, approximately 1 week); if post-concussion symptoms occur at any of the steps, the patient should be returned to the last asymptomatic step and attempt to advance again after another 24 hours of rest (Table 1). Absolutely no athlete should be allowed to return to play on the day of injury.
According to CISG, symptoms persist beyond 10 days in 10% to 15% of patients with concussions. They recommend that in cases of concussion where recover is greater than 10 days, the athlete should be managed in a multidisciplinary setting by clinicians with experience in sports-related concussion, with consideration of other possible pathologies.
Generally, pharmacologic therapy plays 2 roles in the aftermath of a SRC. According to the CISG, these include the alleviation of specific symptoms (headache, sleep, anxiety) and the modification of the pathophysiologic process underlying concussion to reduce the duration of post-concussion symptoms.3 Because there have been few clinical trials of medications that modify the underlying pathophysiologic process, the remainder of this article will focus on symptom alleviation.
Unfortunately, there is still a lack of published evidence delineating the role of pharmacologic agents for SRCs.9 Thus, pharmacologic agents must only be employed by clinicians with experience in the management of concussion, specifically SRC. In addition, medications are not without risk; Meehan suggests that they only should be used if the athlete’s symptoms persist longer than the typical recovery period (>3 weeks, perhaps longer for athletes who have experienced multiple prior concussions), and if the benefits of pharmacologic treatment outweigh the potential risks related to nontreatment.4 Additionally, athletes must be symptom-free and typically off all medications before they can return to play because there is a safety concern that pharmacologic therapy may mask the symptoms of lingering pathophysiology after concussion.