2. 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

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

2. Concussion Symptom Management: Physical Treatment

Physical

Headache (i.e., tension, migraine, cervicogenic)

Service Providers:

  • Physician (Family Physician, Pediatrician, Physiatrist, Neurologist, Sports Medicine Physician, Neurosurgeon)
  • Nurse Practitioner
  • Registered Nurse
  • Physiotherapist (vestibular, muscle tension, cervical spine)
  • Kinesiologist
  • Chiropractor (cervical spine)
  • Clinical Psychologist (Cognitive Behavioural Therapy for symptom management13)
  • Neuro-ophthalmologist
  • Medical specialist in headache management
  • Massage Therapist
Nausea

Service Providers:

  • Physician (Family Physician, Pediatrician, Ear, Nose, and Throat Physician [ENT], Sports Medicine Physician)
  • Nurse Practitioner
  • Registered Nurse
Vomiting

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician)
  • Nurse Practitioner
  • Registered Nurse
Dizziness/ Balance

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician, ENT)
  • Nurse Practitioner
  • Physiotherapist (vestibular specialty)
  • Kinesiologist
  • Athletic Therapist
  • Optometrist (visual assessment)
  • Chiropractor(cervical spine)
Fatigue-Physical

Service Providers:

  • Physician (assess medical cause; Family Physician, Pediatrician, Sports Medicine Physician, Physiatrist)
  • Nurse Practitioner
  • Registered Nurse
  • Physiotherapist
  • Occupational Therapist
  • Kinesiologist
  • Athletic Therapist
Seizures

Service Providers:

  • Physician (Emergency Physician, Family Physician, Pediatrician, Physiatrist, Sports Medicine Physician, Neurologist, Neurosurgeon)
Visual Changes (blurry, double vision, oculomotor dysfunction)

Service Providers:

  • Optometrist (with certification in vision therapy, developmental and functional optometry)
  • Neuro-ophthalmologist
  • Physiotherapist
Phono and Photo –phobia

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician, ENT)
  • Nurse Practitioner
  • Registered Nurse
  • Neuropsychologist
  • Audiologist
  • Optometrist (with certification in vision therapy, developmental and functional optometry)
  • Ophthalmologist
Sleep

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician, Physiatrist, Neurologist, sleep MD)
  • Nurse Practitioner
  • Registered Nurse
  • Clinical Psychologist/Neuropsychologist
  • Occupational Therapist
  • Social Worker
Tinnitus/hearing impairment

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician, ENT)
  • Audiologist
  • Physiotherapist (with vestibular therapy training)
Disorders of taste and smell

Service Providers:

  • Physician (Primary Care Physician, Sports Medicine Physician, ENT, Neurologist)
Disorders of motor speech and swallowing

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician, ENT, Neurologist)
  • Speech language Pathologist
Structural brain or spine injury

Service Providers:

  • Primary Management: Neurosurgeon, Orthopedic Surgeon
  • Follow-up Management: Physician (Physiatrist, Sports Medicine Physician)
Orthopaedic injury co-occurring

Service Providers:

  • Physician (Family Physician, Pediatrician, Sports Medicine Physician, Orthopedic Surgeon, Physiatrist)
  • Physiotherapist
  • Occupational Therapist
  • Chiropractor
C-spine dysfunction (neck pain, postural issues)

Service Providers:

  • Neurosurgeon
  • Orthopedic Surgeon
  • Physiotherapist
  • Chiropractor

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

Cognitive

Fatigue - Mental/Cognitive

Service Providers:

  • Physician (Family Physician, Pediatrician, Physiatrist, Sports Medicine Physician, Neurologist, Psychiatrist)
  • Neuropsychologist
  • Occupational Therapist
Cognitive Communication; Attention/Concentration; Memory; Processing Speed; Word Finding

Service Providers:

  • Neuropsychologist
  • Speech Language Pathologist
  • Occupational Therapist

Functional

Triage/Diagnosis/Management of Symptoms and Decisions about Return to Learn, Return to School and Work, Return to Play

Service Providers:

  • Physician (Emergency Physician, Family Physician, Pediatrician, Sports Medicine Physician, Physiatrist, Neurosurgeon, Neurologist)
  • Nurse Practitioner
  • Neuropsychologist (not medical clearance decisions)
Functional and Treatment Support: For any or all of: Return to Learn, Return to School and Work, Return to Play

Service Providers:

Each discipline has specific and defined roles and it will vary who is involved depending on the specific support needs of individual patients and the practice scope of the healthcare professional.

  • Occupational Therapist
  • Physiotherapist
  • Speech Language Pathologist (social communication)
  • Chiropractor
  • Neuropsychologist
  • Psychiatrist
  • Physician (Family Physician, Pediatrician, Sports Medicine Physician)
  • Optometrist
  • Social Worker
  • Kinesiologist
  • Athletic Therapist

Emotional/Psychosocial

Lability/Irritability; Depressed Affect, Anxiety related symptoms including phobias and Post Traumatic Stress; Performance Issues (fear of re-injury)

Service Providers:

  • Clinical Psychologist/Neuropsychologist
  • Psychiatrist
  • Social Worker (with specific training in therapeutic techniques)
Difficulties (in relation to daily activities and return to learn/work/sport)

Service Providers:

  • Occupational Therapist
  • Neuropsychologist
  • Social Worker
  • Speech Language Pathologist
  • Vocational Rehabilitation Worker
  • Accommodation Specialists/ Academic Coach

Key Messages

  • Treatment activities must be performed within the established scope of practice of specific providers.
  • Multiple healthcare providers may be necessary to effectively and appropriate manage post-concussion symptoms
  • Only registered healthcare treatment activities are profiled here; there is acknowledgement that non-regulated healthcare professional can provide helpful services for post-concussion symptom management