Review Article

Postconcussive Syndrome Following Sports-related Concussion: A Treatment Overview for Primary Care Physicians

Authors: Byron Moran, MD, Prathima Tadikonda, MD, Kevin B. Sneed, PharmD, CRPh, Michelle Hummel, BS, Sergio Guiteau, MD, Eric E. Coris, MD

Abstract

Postconcussive syndrome is an increasingly recognized outcome of sports-related concussion (SRC), characterized by a constellation of poorly defined symptoms. Treatment of PCS is significantly different from that of SRC alone. Primary care physicians often are the first to evaluate these patients, but some are unfamiliar with the available therapeutic approaches. This review provides an overview of the pathophysiology of SRC and descriptions of both pharmacologic and nonpharmacologic treatment options to allow primary care physicians to provide evidence-based care to patients experiencing postconcussive syndrome.

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References

1. Selassie AW, Wilson DA, Pickelsimer EE, et al. Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study. Ann Epidemiol 2013;23:750-756.
 
2. Meehan WP 3rd, d’Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med 2010;38:2405-2409.
 
3. Bakhos LL, Lockhart GR, Myers R, et al. Emergency department visits for concussion in young child athletes. Pediatrics 2010;126:e550-e556.
 
4. Luethcke CA, Bryan CJ, Morrow CE, et al. Comparison of concussive symptoms, cognitive performance, and psychological symptoms between acute blast-versus nonblast-induced mild traumatic brain injury. J Int Neuropsychol Soc 2011;17:36-45.
 
5. Board on the Health of Select Populations, Institute of Medicine. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Model Study Protocols and Frameworks to Advance the State of the Science: Workshop Summary. Washington, DC, The National Academies Press, 2013.
 
6. Levin HS, Diaz-Arrastia RR. Diagnosis, prognosis, and clinical management of mild traumatic brain injury. Lancet Neurol 2015;14:506-517.
 
7. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26.
 
8. Leddy JJ, Kozlowski K, Fung M, et al. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment.NeuroRehabilitation2007;22:199-205.
 
9. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001;36:228-235.
 
10. Li XY, Feng DF. Diffuse axonal injury: novel insights into detection and treatment. J Clin Neurosci 2009;16:614-619.
 
11. King ML, Lichtman SW, Seliger G, et al. Heart-rate variability in chronic traumatic brain injury. Brain Inj 1997;11:445-453.
 
12. Ayalon L, Borodkin K, Dishon L, et al. Circadian rhythm sleep disorders following mild traumatic brain injury. Neurology 2007;68:1136-1140.
 
13. Kalsotra A, Turman CM, Dash PK, et al. Differential effects of traumatic brain injury on the cytochrome p450 system: a perspective into hepatic and renal drug metabolism. J Neurotrauma 2003;20:1339-1350.
 
14. Silver JM, McAllister TW, Arciniegas DB. Depression and cognitive complaints following mild traumatic brain injury. Am J Psychiatry 2009;166:653-661.
 
15. Rapoport MJ, McCullagh S, Streiner D, et al. The clinical significance of major depression following mild traumatic brain injury. Psychosomatics 2003;44:31-37.
 
16. Fann JR, Hart T, Schomer KG. Treatment for depression after traumatic brain injury: a systematic review. J Neurotrauma 2009;26:2383-2402.
 
17. Lee H, Kim SW, Kim JM, et al. Comparing effects of methylphenidate, sertraline and placebo on neuropsychiatric sequelae in patients with traumatic brain injury. Hum Psychopharmacol 2005;20:97-104.
 
18. Markianos M, Seretis A, Kotsou A, et al. CSF neurotransmitter metabolites in comatose head injury patients during changes in their clinical state. Acta Neurochir (Wien) 1996;138:57-59.
 
19. Lee HB, Lyketsos CG, Rao V. Pharmacological management of the psychiatric aspects of traumatic brain injury. Int Rev Psychiatry 2003;15:359-370.
 
20. Rapoport MJ, Chan F, Lanctot K, et al. An open-label study of citalopram for major depression following traumatic brain injury. J Psychopharmacol 2008;22:860-864.
 
21. Turner-Stokes L, Hassan N, Pierce K, et al. Managing depression in brain injury rehabilitation: the use of an integrated care pathway and preliminary report of response to sertraline. Clin Rehabil 2002;16:261-268.
 
22. Bertisch SM, Herzig SJ, Winkelman JW, et al. National use of prescription medications for insomnia: NHANES 1999Y2010. Sleep 2014;37:343-349.
 
23. Williams SE, Ris MD, Ayyangar R, et al. Recovery in pediatric brain injury: is psychostimulant medication beneficial? J Head Trauma Rehabil 1998;13:73-81.
 
24. Silver JM, Yudofsky SC. Psychopharmacology. In: Silver JM, Yudofsky SC, Hales RE (eds): Neuropsychiatry of Traumatic Brain Injury. Washington, DC, American Psychiatric Press, 1994, pp 631-670.
 
25. Neurobehavioral Guidelines Working Group. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J Neurotrauma 2006;23:1468-1501.
 
26. Chew E, Zafonte RD. Pharmacological management of neurobehavioral disorders following traumatic brain injuryVa state-of-the-art review. J Rehabil Res Dev 2009;46:851-879.
 
27. Kile SJ. Diagnosis and treatment of postconcussive neurobehavioral symptoms. Continuum 2006;12:60-71.
 
28. Whyte J, Hart T, Schuster K, et al. Effects of methylphenidate on attentional function after traumatic brain injury. A randomized, placebo-controlled trial. Am J Phys Med Rehabil 1997;76:440-450.
 
29. Meythaler JM, Brunner RC, Johnson A, et al. Amantadine to improve neurorecovery in traumatic brain injury-associated diffuse axonal injury: a pilot double-blind randomized trial. J Head Trauma Rehabil 2002;17:300-313.
 
30. Meehan WP 3rd. Medical therapies for concussion. Clin Sports Med 2011;30:115-124.
 
31. Reddy CC, Collins M, Lovell M, et al. Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. J Head Trauma Rehabil 2013;28:260-265.
 
32. Leddy JJ, Cox JL, Baker JG, et al. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil 2013;28:241-249.
 
33. Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med 2010;20:21-27.
 
34. Riemann BL, Guskiewicz KM. Effects of mild head injury on postural stability as measured through clinical balance testing. J Athl Train 2000; 35:19-25.
 
35. Vibert D, Redfield RC, Hausler R. Benign paroxysmal positional vertigo in mountain bikers. Ann Otol Rhinol Laryngol 2007;116:887-890.
 
36. Diaz DS. Management of athletes with postconcussion syndrome. Semin Speech Lang 2014;35:204-210.
 
37. Horak FB, Jones-Rycewicz C, Black FO, et al. Effects of vestibular rehabilitation on dizziness and imbalance. Otolaryngol Head Neck Surg 1992;106:175-180.
 
38. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010;34:87-93.
 
39. Al Sayegh A, Sandford D, Carson AJ. Psychological approaches to treatment of postconcussion syndrome: a systematic review. J Neurol Neurosurg Psychiatry 2010;81:1128-1134.
 
40. Silverberg ND, Hallam BJ, Rose A, et al. Cognitive-behavioral prevention of postconcussion syndrome in at-risk patients: a pilot randomized controlled trial. J Head Trauma Rehabil 2013;28:313-322.
 
41. Edwards J, Vess J, Reger G, et al. The use of virtual reality in the military’s assessment of service members with traumatic brain injury: recent developments and emerging opportunities. Appl Neuropsychol Adult 2014;21:220-230.
 
42. Pfefer MT, Cooper SR, Boyazis AM. Chiropractic management of postconcussion headache and neck pain in a young athlete and implications for return-to-play. http://www.tihcij.com/Articles/Chiropractic-Management-of-Post-concussion-Headache-and-Neck-Pain-In-a-Young-Athlete-and-Implications-For-Return-To-Play.aspx?id=0000307. Published October 7, 2011. Accessed July 6, 2015.
 
43. Kent R, Pescasio M, Welsh S, et al. A young female misdiagnosed with post-concussive syndrome that responded to manual manipulation: a case report with further investigation into overlapping symptomology. PM R 2013;5:S224.
 
44. Petraglia AL, Winkler EA, Bailes JE. Stuck at the bench: potential natural neuroprotective compounds for concussion. Surg Neurol Int 2011;2:146.
 
45. Barnett EC, McBurney MI, Ciappio ED. w-3 fatty acid supplementation as a potential therapeutic aid for the recovery from mild traumatic brain injury/concussion. Adv Nutr 2014;5:268-277.
 
46. Spinella M, Eaton LA. Hypomania induced by herbal and pharmaceutical psychotropic medicines following mild traumatic brain injury. Brain Inj 2002;16:359-367.
 
47. Johnson EW, Kegel NE, Collins MW. Neuropsychological assessment of sport-related concussion. Clin Sports Med 2011;30:73-88.
 
48. Smits M, Dippel DW, Nederkoorn PJ, et al. Minor head injury: CT-based strategies for management--a cost-effectiveness analysis. Radiology 2010; 254:532-540.
 
49. McGrath N. Supporting the student-athlete’s return to the classroom after a sport-related concussion. J Athl Train 2010;45:492-498.
 
50. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics 2013;132:948-957.
 
51. May KH, Marshall DL, Burns TG, et al. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther 2014;9:242-255.
 
52. Harch PG, Andrews SR, Fogarty EF, et al. A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. J Neurotrauma 2012;29:168-185.
 
53. Kaplan GB, Vasterling JJ, Vedak PC. Brain-derived neurotrophic factor in traumatic brain injury, post-traumatic stress disorder, and their comorbid conditions: role in pathogenesis and treatment. Behav Pharmacol 2010;21:427-437.
 
54. Kutcher JS, McCrory P, Davis G, et al. What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Br J Sports Med 2013;47:299-303.
 
55. Schoenberger NE, Shif SC, Esty ML, et al. Flexyx Neurotherapy System in the treatment of traumatic brain injury: an initial evaluation. J Head Trauma Rehabil 2001;16:260-274.