Gait abnormality, isolated motor delay or focal weakness

PAEDIATRIC

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    Adult

    Stroke/transient ischaemic attack (TIA)

    • Patient with acute neurological symptoms of a stroke; multiple/crescendo TIA
    • New acute symptoms

    Progressive loss of neurological function

    • Acute onset severe:
      • ataxia
      • vertigo
      • visual loss
    • Acute severe exacerbation of known MS

    Seizures/epilepsy

    • Status epilepticus/epilepsy with concerning features:
      • first seizure
      • focal deficit post-ictally
      • seizure associated with recent trauma
      • persistent severe headache > 1 hour post-ictally
      • seizure with fever

    Headache/migraine

    • Headache with concerning features:
      • sudden onset/thunderclap headache
      • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
      • first severe headache age > 50 years
      • severe headache associated with recent head trauma
      • recent onset headaches in young obese females
      • headaches with papilledema
      • >50 years with raised CRP/ESR or if giant cell arteritis or vasculitis suspected

    Movement disorders

    • Ocular

    Other referrals to emergency

    • Altered level of consciousness
    • Bilateral limb weakness with or without bladder and/or bowel dysfunction
    • Acute rapidly progressive weakness (Guillain-Barre Syndrome, myelopathy)
    • Delirium/sudden onset confusion with or without fever

    Paediatric

    Seizures/epilepsy

    • New onset seizures that require emergency care/advice
    • Status epilepticus (convulsive or non-convulsive)
    • Developmental/cognitive/psychiatric regression accompanying new onset or ongoing epileptic seizures
    • New onset seizure with new neurological deficit (e.g. focal weakness, speech impairment, cognitive impairment) – call 000 for emergency assessment for stroke and transport to the Emergency Department
    • Specific seizure types with epileptic encephalopathy risk e.g. infant with possible epileptic spasms
    • High initial seizure burden (>5 seizures, before first AED), excluding typical absence seizures
    • Neonate / infant (<12-month-old) with epileptic seizure onset

    Headaches/migraine

    • Headache with papilledema or change in vision/double vision (excluding established migraine with visual aura) or new neurological examination findings (e.g. sixth nerve palsy, gait disturbance, focal weakness)
    • Headaches that wake at night or headaches immediately on wakening
    • New severe headaches
    • Sudden onset headache reaching maximum intensity within 5 minutes (= explosive onset)
    • Focal neurological features
    • Associated with significant persisting change of personality or cognitive ability or deterioration in school performance

    Functional neurological symptoms

    • The patient is unable to mobilize safely or has frequent falls/seizure like attacksAddition

    Movement disorder

    • Abrupt onset or deterioration of a movement disorder
    • Acute onset of ataxia / chorea
    • Impairment of function i.e. walking, attend school

    Hypotonic infant

    • Tachypnoea (signs of respiratory distress such as accessory muscle use are NOT seen in patients with neuromuscular disorders)
    • Feeding difficulties with weight loss

    Gait abnormality, isolated motor delay or focal weakness

    • Acute onset of (or rapidly progressive) weakness e.g. Guillain Barre syndrome, transverse myelitis
    • Acute onset focal weakness (suspected stroke – call 000)
    • Breathing difficulties (NB tachypnoea may be the only sign of respiratory distress in a child with a neuromuscular condition)
    • Feeding or swallowing difficulties
    • Acute foot drop or acute onset focal neuropathy

    Stroke

    • Acute stroke – call 000 and request urgent transfer (timelines apply for t-PA and thrombectomy for embolic/thrombotic stroke)

    Other neurological conditions

    • Developmental/ intellectual impairment or behavioural / psychiatric disorders with regression
    • Acute encephalopathy, acute confusional state, altered level of consciousness
    • If guidance is required regarding appropriate investigations, please contact the Neurologist on call
    • Refer to HealthPathways or local care pathway
    • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
    • Referral from a health practitioner other than a General Paediatrician may be accepted if there is limited access to Public Paediatric services in the patients' local area
    • A change in patient circumstance (such as condition deteriorating) may affect the urgency categorisation and should be communicated as soon as possible.
    • Clinical urgency is the dominant consideration in the prioritisation of a referral for a child currently in out of home care (OOHC), or at risk of entering or leaving OOHC

    Clinical resources

Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Confirmed diagnosis of a neuromuscular disorder in a child <12 months
  • Confirmed diagnosis of a neuromuscular disorder with a disease modifying treatment (e.g. CMT, myotonic dystrophy)
  • Elevated CK >2000IU
  • A child currently in out of home care (OOHC), or at risk of entering or leaving OOHC, where they have previously been on a waiting list for this problem and were removed without receiving a service.
Category 2
(appointment within 90 calendar days)
  • Progressive muscle weakness over months or plateau of motor development
  • Decline in gross motor function over time e.g. falls, difficulties with stairs, ataxia
  • Deterioration in fine motor skills e.g. handwriting, dressing
  • Muscle wasting or limb asymmetry
  • Elevated CK but < 2000IU
  • Foot deformity for diagnosis where there is a concerned about neuropathy
  • Confirmed diagnosis of a neuromuscular disorder in a child >12 months
  • Confirmed diagnosis of a neuromuscular disorder without a disease modifying treatment (e.g. CMT, myotonic dystrophy)
Category 3
(appointment within 365 calendar days)
  • No category 3 criteria

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • History related to gait abnormality, motor delay or focal weakness
  • Neurological examination findings, including tone, contractures, power, deep tendon reflexes, cranial nerve involvement, muscle wasting
  • Confirmation of OOHC (where appropriate)

3. Additional referral information Useful for processing the referral

  • Birth and developmental history
  • Family history
  • Growth parameters
  • Medication history (including over-the-counter preparations)
  • Significant psychosocial risk factors
  • Allied Therapy reports
  • Investigations including CK and microarray and store DNA – include results if not performed through Pathology Queensland (requested but results not required prior to initiation of referral)
  • Neuroimaging is not clinically indicated if a primary neuromuscular disorder is suspected AND anaesthesia risk maybe high in these patients. If neuroimaging has been done (i.e. clinically indicated e.g. suspected cerebral palsy), arrange image transfer to PACS at the hospital the patient is being referred to, with the imaging reports. If electronic imaging transfer is not available, then a CD of the neuroimaging and report should be sent to the neurologist named in the referral.
  • If the child is in foster care, please provide the name and regional office for the Child Safety Officer who is the responsible case manager.

4. Request

  • Patient's Demographic Details

    • Full name (including aliases)
    • Date of birth
    • Residential and postal address
    • Telephone contact number/s – home, mobile and alternative
    • Medicare number (where eligible)
    • Name of the parent or caregiver (if appropriate)
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander

    Referring Practitioner Details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    Clinical modifiers

    • Impact on employment
    • Impact on education
    • Impact on home
    • Impact on activities of daily living
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander

    Other relevant information

    • Willingness to have surgery (where surgery is a likely intervention)
    • Choice to be treated as a public or private patient
    • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

    • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Last updated: 20 December 2021

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