A Systematic Review of Telehealth and Sport-Related Concussion: Baseline Testing, Diagnosis, and Management

Abstract

Background: The use of telehealth has increased as a result of the COVID-19 pandemic. As sports at all levels resume, sports medicine physicians may be interested in how telehealth can be used for concussion care. Questions/Purpose: We sought to assess how telehealth has been used in the baseline testing, diagnosis, and/or management of concussion. Secondarily, we sought to assess the strengths and weaknesses of telehealth for concussion care and identify aspects of concussion care for which telehealth has not yet been studied. Methods: A systematic review was performed in September 2020 of PubMed and Embase using the following terms: concuss*, “mild traumatic brain,” “head injur*,” telehealth, telemedicine, telecare, “mobile health,” m-health, virtual. Studies included were original research articles investigating the use of telehealth in the care of concussion (including baseline testing, diagnosis, and management), published in English, and had full text available. Results: A total of 356 articles were screened, of which 5 were determined to meet inclusion criteria. These articles described the use of telehealth for managing concussion in military and rural settings. No articles involved the use of telehealth for baseline concussion testing of athletes or for sideline evaluation. Conclusion: Despite the limited original research on the use of telehealth for concussion care, the articles identified provide a foundation for exploring the potential value of telehealth in the office practice and sports team setting. Telehealth may expand the ability of a sports medicine physician to provide timely and effective concussion care to athletes during the COVID-19 pandemic and beyond. More rigorous research is needed.

Introduction

The COVID-19 pandemic disrupted established ways of most aspects of life, including the provision of medical care [19]. Prior to COVID-19, telehealth was used in a limited capacity and had not been widely adopted in most areas of medicine. As a result of COVID-19, however, the limits of what medical services can be provided by telehealth have been tested [12]. While many clinicians were becoming acquainted with treating patients by telehealth early in the pandemic, nearly all sports at every level were suspended [3,14,23]. After 6 months of the pandemic in North America, sports started to resume at the youth, collegiate, and professional level. As sports participation increases, so does the risk of sport-related concussion. Equipped with this new tool of telehealth, sports medicine physicians may be interested in how it can be used for concussion care.

Despite appropriate precautions, in-person healthcare visits confer a risk of COVID-19 transmission. Assuming this risk must be justified when there is active community spread of the virus [10]. As the pandemic continues, physicians are learning to balance the need for providing in-person care and minimizing risk. For this reason, sports medicine physicians are reevaluating how care is provided to athletes. In the context of concussion care, traditionally a sports medicine physician and athletic trainer would be providing in-person baseline testing, diagnosis, and management. Baseline concussion testing for team sports is commonly performed in a group setting where multiple athletes are in the same room taking the test on separate computers. This approach to concussion care and especially the baseline testing of teams may be inappropriate during certain phases of the COVID-19 pandemic.

Sports medicine physicians should be aware of the current knowledge regarding telehealth for concussion care when considering implementing such a program. While telehealth has been previously proposed as a platform for providing concussion care in rural settings, it could have broader utility during the COVID-19 pandemic and beyond [9,24,33]. We sought to conduct a systematic review to answer the following questions about the use of telehealth in the care of concussion.

1. How has telehealth been used in the baseline testing, diagnosis, and/or management of concussion?

2. What strengths and weaknesses have been observed in telehealth for concussion care?

3. What aspects of telehealth concussion care have yet to be studied?

4. While these questions are relevant during the COVID-19 pandemic, many of the lessons learned about the capabilities of telehealth will likely influence the practice of sports medicine into the future.

Search Strategy and Criteria

While we were interested primarily in the sports setting, we conducted a broad systematic review to assess the use of telehealth for concussion care in all settings. The following search strategy was used in PubMed and Embase in September 2020:

((concuss*) OR (“mild traumatic brain”) OR (“head injur*”))

AND

((telehealth) OR (telemedicine) OR (telecare) OR (“mobile health”) OR (m-health) OR (virtual))

The search produced 178 results in PubMed and 306 results in Embase (Fig. 1). There were 6 duplicates within Embase and 123 duplicates between the 2 databases, leaving 355 unique results. Titles and abstracts from the initial search were screened for eligibility. Full-text assessment for eligibility was performed for 55 articles. Articles were included in this systematic review if they were original research articles describing the use of telehealth in the care of concussion (including baseline testing, diagnosis, and management), published in English, and had full text available. References from the relevant articles identified by the PubMed and Embase searches were reviewed for additional articles. This resulted in 5 original research articles for qualitative synthesis.

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 flow diagram. mTBI mild traumatic brain injury.

Results

This systematic review identified a small number of original research articles describing the use of telehealth for the management of concussion. Two articles involved telehealth in the military setting. Yurkiewicz et al described the experience of the Army Knowledge Online Telemedicine Consultation Program that was used for the care of 131 cases of traumatic brain injury (TBI) of which 53% were for mild traumatic brain injury (mTBI) or concussion. The mean response time for TBI consults was under 3 hours [34]. An abstract from a presentation at the International Brain Injury Association’s 12th World Congress on Brain Injury in 2017 described the experience of telehealth for mTBI patients in a geographically dispersed region of Germany that includes active duty military personnel. The authors describe improved medical readiness and cost savings resulting from the telehealth program [15].

Two articles involved telehealth in the rural setting, specifically for the management of concussion. A case report from 2012 described the management by telehealth of a youth athlete with a sport-related concussion in rural Arizona [29]. However, the outcome of the telehealth visit described in the case report was that the youth athlete was to rest from exercise and schedule an in-person visit with a concussion specialist. Ellis et al reported the experience of 20 pediatric concussion patients in rural Canada who were managed by telehealth; half of these concussions were sport-related (hockey) [8]. All but 2 participants clinically recovered: 1 was referred to a headache neurologist and another remained in treatment at time of publication. The median time from injury to initial consultation the concussion program was 10 days, and the median number of telehealth visits was 2. Only one patient required imaging after being referred to the program. The authors estimate over $40,000 in cost savings.

Vargas et al performed a pilot study to evaluate the use of telehealth for sideline concussion evaluation in college football [30]. Eleven players with suspected concussions underwent an in-person assessment that was observed remotely by a neurologist using telehealth. The neurologist’s assessments agreed with those of the in-person providers for return to play decisions. No article described the use of telehealth to facilitate baseline screening of athletes.

Discussion

Despite the limited original research on the use of telehealth for concussion care, the articles identified provide a foundation for exploring the potential value of telehealth in the office practice and sports team setting. While there are barriers and limitations to using telehealth for caring for sports teams [31], COVID-19 has forced many sports medicine physicians to overcome the technical challenges of incorporating it into daily practice. Here, we present additional considerations for the use of telehealth for the care of sport-related concussion. Although no studies described the use of telehealth for baseline concussion testing, it may be useful and even have a few advantages. Baseline concussion testing is not a mandatory component of concussion care, according to the Berlin Consensus Statement on Concussion in Sport, but it is recommended by the National Collegiate Athletic Association (NCAA) [6,21]. Since it is typically performed in conjunction with the preparticipation exam (PPE), an in-person visit would be needed to complete the comprehensive physical exam of the PPE [1,17]. However, if there is a need to limit in-person exposure, much of the baseline concussion testing could be done by telehealth.

This systematic review has several limitations. First, only 5 studies were included. Second, the studies investigated adults and children with concussion, mixing populations that may need different treatment considerations. Third, the studies had varying methodologies (ie, case study, pilot study), limiting our ability to measure the effectiveness of telehealth for concussion screening and management. Such limitations must be weighed when considering our results.

Baseline testing generally involves a concussion history, assessment with the Standardized Concussion Assessment Tool 5 (SCAT5) and, possibly, neurocognitive testing as well [13]. A concussion history can often be reliably provided by a youth athlete, however, inconsistencies were more common in male athletes, those with attention deficit hyperactivity disorder (ADHD), and those with a greater number of prior concussions [32]. Obtaining a concussion history from a youth athlete by telehealth could allow for parents to provide additional information about past injuries and recovery if baseline testing would otherwise be performed without a parent present. As for other components of baseline concussion testing, SCAT5 includes symptom evaluation, cognitive screening (orientation, memory), concentration (digits backwards, months in reverse order), and neurological screen (reading, cervical spine range of motion, finger-to-nose, tandem gait, and balance examination) [7]. All the components of SCAT5 except the finger-to-nose test could be effectively adapted to remote testing (Table 1). Computer-based neurocognitive testing could be performed at an athlete’s home but administered or proctored using telehealth to ensure proper testing procedure. French et al found that although environment did not affect test performance, those who tested in an individual testing environment had, on average, a higher concussion symptom severity score than those who underwent testing in a group [11]. Other tests that may be used in baseline testing such as the Vestibular Ocular-Motor Screen would require another examiner to be physically present with the athlete [22]. Athletes with more complex neuropsychological or concussion history may require formal testing with a neuropsychologist, and there may be limitations to using telehealth for such tests [2].

Table 1.

Components of concussion care possible by telehealth.

	Possible by telehealth		Not possible by telehealth
Baseline testing	Without athletic trainer assistance	With athletic trainer assistance
	Neurologic assessment - Concussion history - Symptoms - Mental status - Gross motor SCAT5 - Symptom evaluation - Cognitive screening - Neurologic screen (not finger nose coordination test) - Delayed recall Proctoring computer-based neurocognitive testing	Neurologic assessment - Cranial nerves - Motor - Reflexes - Sensory - Coordination Vestibular/ocular-motor screening SCAT5 - Neurologic screen (finger nose coordination test)
Diagnosis	Without athletic trainer assistance	With athletic trainer assistance	Imaging of brain or cervical spine
	Maddocks questions Neurologic assessment - Symptoms - Mental status - Gross motor SCAT5 (see above) Proctoring computer-based neurocognitive testing	Cervical spine assessment Neurologic assessment - Cranial nerves - Motor - Reflexes - Sensory - Coordination Vestibular/ocular-motor screening SCAT5 (see above)
Management	Directing cognitive and physical rest, followed by guiding athlete on return to play protocol Proctoring computer-based neurocognitive testing Telehealth cervical spine physical therapy Telehealth neuropsychological consultation Telehealth cognitive behavioral therapy		Imaging of brain or cervical spine (if indicated) Hands-on cervical spine physical therapy Vestibular therapy Vision therapy Complete neuropsychological assessment

SCAT5 Sport Concussion Assessment Tool – 5th Edition.

The sideline evaluation of an athlete with a suspected concussion begins with ascertaining the mechanism of injury and observing for immediate signs of concussion (loss of consciousness, gross motor instability, blank stare, seizure-like movements, and tonic posturing) [13]. Once removed from play, the athlete is typically escorted to a quieter environment such as the locker room or a sideline tent where he or she can be more thoroughly assessed for symptoms and changes in memory, concentration, and balance [7]. The role of telehealth in the sideline management of a suspected concussion is limited given that in-person evaluation is required to identify red flags, such as cervical spine tenderness or motor/sensory deficits.

However, telehealth may supplement the sideline evaluation in certain circumstances, such as when a player is injured during practice or other scenarios when an athletic trainer is the only medical team member present. In those situations, a team physician consulting by telehealth can work with the in-person athletic trainer to complete the full assessment for a suspected concussion. The National Athletic Trainers’ Association position statement on the concussion states, “When a physician is not readily available, the AT should be more conservative when interpreting the clinical-examination results and making the injury diagnosis” [4]. Therefore, when a sports team travels without a team physician, it can be advantageous to use telehealth to involve the physician in medical decision-making. In addition to the team physician’s prior knowledge of the athlete and his or her concussion history, the team physician can better identify changes in behavior and mood compared to medical staff from the opposing team. If the mechanism of injury or immediate signs following the injury were not clearly observed by the on-site medical team, video footage could be reviewed remotely by the team physician and reported by telehealth to the medical staff in the locker room when video review or concussion spotters are not available on site. Since a mid-game sideline evaluation of a possible concussion is often time-sensitive, coordinating the logistics of incorporating telehealth would need to be worked out in advance to avoid delay. Although 1 study demonstrated the feasibility of a neurologist consulting by telehealth during an acute concussion evaluation, it did not demonstrate the added value of the neurologist when a sideline provider was present as the neurologist’s return to play decision was the same as the sideline provider’s [30].

In the days following a suspected concussion, an athlete undergoes a more comprehensive assessment, which typically occurs in the office or training room [13,21]. As with the sideline or locker room assessment, an in-person visit is necessary for evaluating the cervical spine and performing a complete neurologic examination. However, a team’s location or personnel restrictions can prevent an in-person assessment by a physician, such as during the COVID-19 pandemic. In these circumstances, a similar outcome can be achieved by having an athletic trainer perform the in-person examination while the team physician consults by telehealth. This ability to collaborate by telehealth on a comprehensive subacute concussion evaluation may expedite the final diagnosis—especially compared to waiting for the athlete return from the road.

Much of the treatment of sport-related concussion is tailoring the necessary cognitive and physical rest depending on the athlete’s symptoms. When performed by telehealth, this aspect of concussion care has been shown to be safe and effective in rural and military settings [8,15,29,34]. Although there may not be the same logistical challenges of managing most sport-related concussions in the office setting, there are reasons when a sports medicine physician may choose to manage an athlete with a concussion, at least in part, by telehealth.

The most appropriate candidate for concussion management by telehealth would be an athlete who does not have any of the following: a history of multiple concussions, a history of prolonged recovery after a concussion, persistent changes from baseline on neurologic exam, cervicogenic symptoms, or vestibular-ocular symptoms. For select athletes, telehealth will have some advantages for follow-up concussion management. First, patients with concussions have been found to have slower response times during driving simulations; in one study, half of sports medicine physicians usually or almost always counseled against driving when athletes were experiencing concussion symptoms [16,18]. Telehealth enables them to avoid driving. Second, a study of school-aged athletes found that a median of 4 days of school were missed following a concussion [26]. Selectively using telehealth for concussion management may prevent a young athlete from missing additional school, by avoiding mandatory travel to the physician’s office. One Veterans Affairs hospital calculated an average time savings of 142 minutes per visit [27]. However, a limitation of telehealth managing concussion is that computers and electronics can exacerbate symptoms (in fact, avoidance of such devices is often recommended during the recovery period) [20]. This was demonstrated in a telehealth study that took place in a pediatric headache clinic, when a patient reported that screen light hurt her eyes [25].

Telehealth can also be used to facilitate multidisciplinary care and improve access to specialties that are not locally available. Telehealth enables visits and the participation of multiple members of the athlete’s care team including parents, coaches, the team’s athletic trainer, team physician, physical therapist, neurologist, vestibular therapist, sport psychologist, and other medical specialists. This can be done even when the athlete is seeing the specialist or therapist in-person. For example, a team’s athletic trainer can join an in-person visit with a vestibular therapist via telehealth so that similar treatments can be continued in the training room. While studies on the effectiveness of specific concussion treatments delivered by telehealth are limited, one study showed promising results for internet-based vestibular therapy for chronic vestibular syndrome [28]. Lastly, managing sports-related concussion by telehealth could eventually be supplemented by incorporating current and emerging biometrics. Heart rate monitors and mobile phone applications for balance testing may have a role in the future management of concussions, but further research is needed to demonstrate the clinical utility [5].

As the COVID-19 pandemic continues, more novel ways of using telehealth will be discovered. When it resolves, sports medicine physicians will likely return to providing in-person concussion care in the vast majority of cases; in-person visits will always have advantages over a telehealth visit. However, recent lessons learned about the use telehealth may ultimately facilitate greater access for athletes to sports medicine physicians and other concussion specialists in situations that were previously precluded by logistics and geography.