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Pharmacological Interventions in Sport-Related Concussion

A review of treatment options and case examples provide insight into post-concussion management.
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In recent years, there has been increasing attention paid to the impact of concussion and the potentially detrimental effects this type of injury may have.1,2 Langlois et al identified an approximate 1.6 to 3.8 million concussions occurring annually in the United States.3 In particular, sport-related concussion (SRC) is a type of injury that has seen a considerable increase in identification, understanding, and research. Estimates report that traumatic brain injury in youth athletes (ages 0 to 19) account for approximately 173,285 emergency room visits yearly, a trend that continues to rise.4 High-profile cases involving athletes with concussive injuries remain forefront in the news cycle, and SRC has been a major health concern in young adult and college-aged athletes as well, occurring at an incidence rate of 4.47 per 10,000 athletes exposures (AEs).5

Lincoln et al6 provided dramatic representation of the increase in rate of concussion in boys and girls youth athletics over 10 years. They noted an average yearly increase of 15.5%, from 0.12 per 1000 AEs in 1997-1998 to 0.49 per 1000 in 2007-2008.6 The findings of Zuckerman et al further suggested that overall incidence of concussion in NCAA athletes did not increase between the 2009-2010 and 2013-2014 seasons, although certain sports (eg, men’s football, women’s ice hockey, and men’s lacrosse) did show statistically significant increases.5 (see Table 1).

As the scope of the problem grows, efforts are aimed at further understanding the factors associated with SRC that impact treatment, time course, complications, and return-to-play (RTP) and return-to-learn (RTL) protocols.

As defined by the Concussion in Sport Group, sport-related concussion is a traumatic brain injury induced by biomechanical forces.6-8 Concussion may be caused by an impulsive force resulting from an impact to the head or transmitted to the head from another part of the body. There is typically a rapid onset of short-lived impairments in neurological function that resolve spontaneously. While in some cases there may be neuropathological changes, the acute symptoms likely reflect a functional impairment rather than a structural problem. A range of clinical signs and symptoms are typically resolved following a sequential course.7

The pathophysiology of concussion involves a complex cascade of biochemical processes that may lead to a dysregulation of ions and neurotransmitters, and increases in free radicals and inflammatory mediators.9 Common clinical presentations involve physical signs (loss of consciousness, amnesia), behavioral changes (irritability), cognitive impairment (slowed reaction times), sleep disturbance, and symptoms categorized as somatic (headache), cognitive (in a fog), and/or emotional symptoms (mood lability).7

The majority of sport-related concussions resolve within 14 days of initial injury.10 These cases often benefit from behavioral therapies (eg, physical and cognitive rest) and careful adherence to regulated RTP and RTL protocols, according to Meehan’s widely adhered-to recommendations in Medical Therapies for Concussion. 11 (Table 2 offers a summary of steps and goals.)

Both the RTP and RTL protocols are a graded set of activities designed to reintegrate athletes into physical and cognitive activity while mitigating the risk of symptom exacerbation after a concussion.12-14 RTP is a standardized strategy proposed by the Concussion in Sport Group,6 intended to be implemented following a 24- to 48-hour period of rest after initial insult. Once initiated, each stage (in youth and adolescents) is adhered to for no less than 24 hours before advancing to the next stage (some collegiate and professional RTP protocols do not mandate 24 hours per step). In the event of worsening of symptoms, the athlete is advised to cease activity; once symptoms have resolved, the athlete then returns to the previous step. If symptoms persist, referral to a clinician with expertise in the management of concussion may be warranted.14

However, approximately 10% of SRCs may persist longer than two to three weeks, at which point the symptoms may be classified as post-concussion syndrome (PCS).12-15 Patients suffering from PCS may benefit from pharmacological interventions. While there are relatively few standardized or evidence-based approaches to pharmacotherapy in concussed athletes, there are recommendations and treatments to consider. No medication to date has proven to speed recovery from traumatic brain injury, 16 and different categories of medication may be useful to target specific symptoms related to concussive injuries.


Case #1: Delayed Appearance of Concussion Symptoms in 10-Year-Old

A 10-year-old girl presented to a sports medicine specialty clinic approximately one month after sustaining a concussion while playing softball. This was her first lifetime concussion. There was no reported loss of consciousness or amnesia after the initial insult, and no other injuries were sustained at that time. Initial symptoms included headache, nausea, and dizziness. Shortly after, she began to experience more severe dizziness, nausea, and fatigue, as well as elevated distractibility, issues with memory, poor concentration, and mental fogginess. She also reported worsening in headaches, and it was noted that there was a strong family history of migraine. She missed 15 days of school before being able to gradually increase her attendance by several hours a day.

Last updated on: December 7, 2017
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