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Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups?
  1. Michael Makdissi1,2,
  2. Gavin Davis1,3,4,
  3. Barry Jordan5,
  4. Jon Patricios6,7,
  5. Laura Purcell8,
  6. Margot Putukian9
  1. 1The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, University of Melbourne, Heidelberg, Victoria, Australia
  2. 2Centre for Health, Exercise and Sports Medicine, University of Melbourne, Melbourne, Australia
  3. 3Department of Neurosurgery, Cabrini Medical Centre, Malvern, Victoria, Australia
  4. 4Murdoch Children's Research Institute, Parkville, Victoria, Australia
  5. 5Brain Injury Program, Burke Rehabilitation Hospital, White Plains, New York, USA
  6. 6Sports Concussion South Africa, Johannesburg, South Africa
  7. 7The Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
  8. 8Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
  9. 9Department of Athletic Medicine, Princeton University, University Health Services, Princeton, New Jersey, USA
  1. Correspondence to Dr Michael Makdissi, The Florey Institute of Neuroscience and Mental Health, Austin Campus, Melbourne Brain Centre, 245 Burgundy St Heidelberg Australia,  Heidelberg, VIC 3084, Australia; makdissi{at}


Background One of the key difficulties while managing concussion in sport is that there are few prognostic factors to reliably predict clinical outcome. The aims of the current paper are to review the evidence for concussion modifiers and to consider how the evaluation and management of concussion may differ in specific groups.

Methods A qualitative review of the literature on concussion was conducted with a focus on prognostic factors and specific groups including children, female athletes and elite versus non-elite players. PubMed, MEDLINE and SportsDiscus databases were reviewed.

Results The literature demonstrates that number and severity of symptoms and previous concussions are associated with prolonged recovery and/or increased risk of complications. Brief loss of consciousness (LOC) and/or impact seizures do not reliably predict outcomes following a concussion, although a cautious approach should be adopted in an athlete with prolonged LOC or impact seizures (ie, >1 min). Children generally take longer to recover from concussions and assessment batteries have yet to be validated in the younger age group. Currently, there are insufficient data on the influence of genetics and gender on outcomes following a concussion.

Conclusions Several modifiers are associated with prolonged recovery or increased risk of complications following a concussion and have important implications for management. Children with concussion should be managed conservatively, with an emphasis on return to learn as well as return to sport. In cases of concussions managed with limited resources (eg, non-elite players), a conservative approach should also be taken. There should be an emphasis on concussion education in all sports and at all levels, particularly in junior and community-based competitions.

  • Concussion
  • Head Injuries
  • Contact Sports

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