2. Post-concussion care and concussion clinics should have direct access to a physician with experience in concussion management to provide ongoing involvement regarding medical stability, trajectory of care, need for medical speciality referral and decisions on clearance to return to activity. (This can be provided through a physician working in a clinic or a physician associated through a formal arrangement.)
Background:
The majority of individuals who experience concussion will recover within suggested timelines (2 weeks) for children and youth) with conservative management. For persons with a straightforward recovery, medical involvement for diagnosis and guidance of progressive recovery back to activities may be all that is required.
Some individuals will continue to experience prolonged symptoms, and will require medical re-assessment and may need management by an interdisciplinary team. A physician should have the training to identify those patients at risk for prolonged post-concussion symptoms and be able to ensure that all necessary follow-up, diagnostic testing, consultant referrals and treatment are provided in a timely, appropriate manner for these patients.
A physician is the only healthcare provider who can rule out other medical diagnoses, consider co-morbidity or pre-morbidity, make treatment decisions for medical issues and symptoms, manage need for medications, make specialist referrals, and provide clearance for return to work/school/play. While other healthcare providers may have some of the necessary knowledge and can advise a physician regarding trajectory of care and treatment decisions, a physician is regulated to make these decisions.
In some cases a nurse practitioner (NP) will be the available medical provider. There are some limitations to NPs that preclude them for having all of these responsibilities without an involved physician, when required, and prescription medications that may be off label
What this standard means:
The physician involved could be a family or sport physician, a pediatrician, a physiatrist, or physician affiliated with a concussion clinic. It is necessary that there be appropriate medical communication (“hand-over” of the responsibility of care) as patients move through the post-concussion care pathway to ensure clarity about the most responsible physician (OHIP term) for care decisions.
It is incumbent upon all healthcare providers to ensure that patients seen for post-concussion care are followed by a medical practitioner. Although having a physician directly working at a concussion clinic is optimal, a formal arrangement is also acceptable involving a consulting physician with expertise in diagnosing and managing post-concussion care being in regular communication with the clinic, having agreed to see patients from the clinic and consult in a timely manner on an as needed basis with the clinic service providers.
Medical clearance decisions for return to activity can only be made by a physician or nurse practitioner. This is often made after consulting with other treating professionals involved in the care of the specific patient, such as neuropsychology or physiotherapy.
As indicated in Standard 1, neuropsychologists are regulated to diagnose a concussion and do so only after medical evaluation or in collaboration with a physician to ensure that any medical issues are identified and managed. They are trained to identify if patients should be seen by medical specialists for issues requiring medical management and/or would indicate a diagnosis other than concussion. They can assess for readiness and supports required for return to work/school/play but clearance must be provided by a medical practitioner.
Physicians and nurse practitioners will need to have completed the necessary training and educational materials so that they are appropriately prepared to act as the primary care provider coordinating and managing post-concussion care. This training should involve knowledge of Clinical Practice Guidelines, familiarity of local/regional post-concussion care providers and resources. If a medical practitioner does not feel that they have the necessary experience in concussion to fully manage a patient with prolonged symptoms, it is recommended that he/she refer to a concussion clinic or network of providers with specialized training, knowledge and experience, while still maintaining medical oversight.
Tools and Resources:
Concussion Clinical Practice Guidelines: Adult, Pediatric, Sport