7. Referral Indicators

In an ideal world it would be desirable to have numerous different healthcare professionals working in one setting who can address all potential persistent symptoms. However, this may not a good use of resources and expertise. The variation of patient needs and symptoms sometimes call for a referral to healthcare professionals who are external to a clinic or network providing post-concussion care.

It is incumbent upon all healthcare professionals to understand and work within their regulated scopes of practice and individual level of competency, which requires that referrals be made when symptoms are outside of a healthcare professional’s scope of practice or level of competency.

Referral indicators were developed to guide healthcare providers to address specific patient symptoms by ensuring appropriate referrals to other regulated healthcare professionals. The intention is to get patients the appropriate and required care within a timely manner.

Information that is Important to Include in a Referral to Health Care Providers

The following information is considered critical to convey in a referral as it improves the quality/appropriateness of the referral (including risk factors) which can thus improve triage.

  • Age
  • Date of injury
  • Specific reason for referral
  • Presence of risk factors:
    • high score on either the Post-Concussion Symptom Scale (PCSS) >40, or the Rivermead Post-Concussion Questionnaire
    • female gender
    • previous concussion history
    • migraines/headaches
    • history of neurological conditions or complex medical issues/conditions
    • premorbid history of mental health issues, learning disabilities, behavioural issues, attentional problems
    • current symptoms consistent with depression/anxiety or other mental health conditions
    • signs/symptoms of vestibular abnormalities
    • signs/symptoms of visual abnormalities
    • signs/symptoms of cognitive difficulties
    • changes in sleep patterns, difficulty sleeping
    • increased symptoms with return to school, work, or exercise
    • returning to a contact sport activity

It is incumbent on the practitioner making the referral to consider the underlying etiology of the symptom when making the referral, in order to choose the appropriate registered healthcare professional to refer to. For example, headache may be cervicogenic, tension, migraine or vestibular/ocular in origin, thus the referral would go to different practitioners depending on scope of practice.

Audiologist

For the following symptoms

  • Persisting tinnitus
  • Sensitivity to sound
Chiropractor

For the following symptoms

  • C-spine dysfunction and neck pain
  • Some dizziness, balance or postural issues
  • Persisting headache not responding to other therapies
  • Requiring support returning to physical activities
Ear, Nose, and Throat Physician

For the following symptoms

  • Persisting tinnitus, sound sensitivity, hearing loss
  • Disorders of taste/smell, disorders of motor speech/swallowing
  • Treatment-resistant vertigo, dizziness, nausea
Kinesiologist

For the following symptoms

  • Requiring support returning to physical activities
  • Dizziness and vestibular issues
  • Physical fatigue
  • Headache
Massage Therapist

For the following symptoms

  • Headache
  • Muscular issues
Neurologist
11For the following symptoms

  • Seizures, movement disorder or focal neurological deficits
  • Cognitive fatigue and confusion, sleep difficulties
  • Treatment-resistant post-traumatic headaches
  • Disorders of taste/smell, disorders of motor speech/swallowing
  • Requiring decisions about return to learn, school, work, and play
Neuro-ophthalmologist

For the following symptoms

  • Vision loss, blurry vision/diplopia
  • Headache
  • Persisting symptoms of post-trauma vision dysfunction
Neuropsychologist / Clinical Psychologist
1For the following symptoms

  • Persisting cognitive deficits/fatigue impacting function, sleep, performance issues.
  • Requiring support returning to school, work, normal activities
  • Persistent depressive and anxiety symptoms, PTSD and suicidal ideation
  • Sensitivities to light and sound
  • Sports performance issues
Neurosurgeon

For the following symptoms

  • Structural brain or spine injury
Nurse Practitioner

For the following symptoms

  • Requiring decisions about return to learn, school, work, and play
  • Physical fatigue, sleep difficulties
  • Headache
  • Sensitivities to light and sound, vestibular abnormalities, dizziness, nausea and/or vomitting
Nurse

For the following symptoms

  • Physical fatigue, sleep difficulties
  • Headache
  • Sensitivities to light and sound, nausea and/or vomitting
Occupational Therapist
1, 30For the following symptoms

  • Requiring support for integration to school or work and day-to-day activities
  • Cognitive deficits
  • Fatigue (mental/cognitive)
  • Sleep difficulties
  • Co-occurring orthopaedic injuries
Optometrist (with expertise in vision therapy, developmental and functional optometry)

For the following symptoms

  • Dizziness/balance
  • Vision loss, blurry vision
  • Sensitivities to light
  • Requiring support with return to activities
Orthopaedic Surgeon

For the following symptoms

  • Co-occurring orthopaedic injuries
  • Structural spine injury
Physiatrist

For the following symptoms

  • Requiring decisions about return to learn, school, work, and play
  • Persisting post-traumatic headaches
  • Physical, cognitive and emotional symptoms impacting a patient’s function, that are not already being addressed by another specialist
Physician/ Sports Medicine Physician

For the following symptoms

  • Requiring decisions about return to learn, school, work, and play
  • Sleep difficulties, physical fatigue
  • Headache
  • Seizures
  • Sensitivities to light and/or sound, vestibular abnormalities, dizziness, nausea and/or vomitting, tinnitus
  • Disorders of taste and smell, disorders of motor speech and swallowing
  • Co-occurring orthopaedic injury
  • Structural brain or spine injury
Physiotherapist / Vestibular Therapist

For the following symptoms

  • Decreased balance, persisting dizziness, benign paroxysmal positional vertigo (BPPV), tinnitus
  • Oculomotor dysfunction
  • Headache
  • C-spine dysfunction, neck pain, postural issues
  • Physical fatigue
  • Co-occurring orthopaedic injury
  • Requiring support returning to activities
Psychiatrist

For the following symptoms

  • Persisting symptoms of depression/anxiety including Post traumatic stress disorder (PTSD)
  • Suicidal ideation
  • Requiring support returning to learn, work, and play
Social Worker
1For the following symptoms

  • Need Education/support of family members
  • Depression/anxiety
  • Sleep difficulties
  • Financial difficulties
  • Difficulty with return to regular activity (fatigue, sleep, performance issues) and community integration
Speech Language Pathologist
30For the following symptoms

  • Cognitive communication deficits (word finding, word formulation, reading comprehension, processing)
  • Requiring support for return to activity (social communication , school)
  • Disorders of motor speech and swallowing

Key Messages

  • Concussion management is symptom-based
  • Referral indicators were developed to guide healthcare providers to facilitate appropriate referrals
  • Healthcare providers must be mindful to always work within their scope of practice and their level of competence
  • Focus should be on getting patients the right care in a timely manner