Concussion Symptom Management

It is recognized that providers are trained, qualified and regulated to manage specific post-concussion symptoms and will need to refer to other professionals in order for all potential post-concussion symptoms to be effectively and appropriately managed within legislated scopes of practice. The Symptom Management Chart has been developed to demonstrate which providers are regulated to treat specific symptoms.

Only the diagnosing healthcare professionals, for whom it is within their legislated scope of practice to provide diagnosis for neurologically-based conditions, can make a concussion diagnosis (Physicians, Nurse Practitioners and Neuropsychologists). A full diagnosis involves an evaluation of the mechanism of injury, potential risk factors that may have a negative impact on recovery, clinical history and current symptom presentation.

Medical assessment must first be made by a Physician and/or Nurse Practitioner in order to address any medical issues and conditions related to or concurrent with concussion. They will take any necessary actions and make referrals for medical management and treatment. Neuropsychologists are also regulated to diagnose a concussion and do so after medical evaluation or in collaboration with a physician to ensure that any medical issues are identified and managed. Final clearance decisions regarding return to activity (i.e. work, school, sports), can only be made by Physicians and Nurse Practitioners, after consulting with other treating professionals involved in the care of the specific patient.

In addition to regulated healthcare professionals, non-regulated professionals or paraprofessionals (i.e., athletic therapist, occupational therapist assistant / physical therapist assistant, recreation therapist) can also provide care for persons after concussion. There are many community-based organizations (i.e., local brain injury associations) that provide both beneficial information and peer support and should be considered in addition to professionally-provided treatment and management from regulated health care professionals.

The following are the different types of health care professionals for whom it is within their recognized scope of practice to perform the core discipline specific functions:

1. Diagnosis, Medical Treatment and Clearance Decisions
2. Physical Treatment
3. Cognitive, Functional and Emotional Support

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1. Diagnostic Activities

(Physician, Nurse Practitioner, Neuropsychologist)

• Medical Assessment (Physician, Nurse Practitioner): triage symptoms, rule-out need for specialist medical follow up for any significant medical/neurological/musculoskeletal issues
• Diagnostic Assessment (Physician, Nurse Practitioner, Neuropsychologist): an evaluation of the mechanism of injury, potential risk factors that may have a negative impact on recovery, and current symptom presentation. Note: Neuropsychologists can make the clinical diagnosis but not any medical diagnoses. Other healthcare providers can suspect a concussion but cannot diagnose one.
• Medical clearance (as a diagnosis of health status, this can only be made by Physician or Nurse Practitioner in Ontario): return to activity (work, school, play, recreation, etc.).

Note: Other healthcare providers can assess for readiness and supports required for return to work/school/play but clearance must be provided by a medical practitioner (Physician or Nurse Practitioner).

Medical Treatment and Referral Decisions post-concussion

The following may be identified during medical assessment and diagnosis and will warrant follow up and possible referral to appropriate medical specialists and healthcare providers consistent with their scopes of practice.

• Cervicogenic headaches and whiplash-type injuries
• Vestibular and oculomotor dysfunction
• Migraine and post-traumatic headaches
• Psychiatric/psychological disorders
• Management strategies related to cognitive remediation, reintegration to work, life, sports and school
• Hearing impairment or temporal bone pathology
• Sleep disorders
• Structural brain or spine injury
• Co-existing orthopedic injury
• Seizure disorders

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2. Concussion Symptom Management: Physical Treatment

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3. Concussion Symptom Management: Cognitive, Functional and Emotional Support

Cognitive

Functional

Emotional/Psychosocial