The Role of Telehealth in Sideline Management of Sports-Related Injuries

Abstract

The COVID-19 pandemic has affected the ability of the sports medicine physician to be present to participate in in-person sideline evaluation of the injured athlete. The purpose of this review is to assess existing literature regarding the utilization of telehealth for sideline evaluation and management of the injured athlete, as well as to identify further areas of research. With the rapid incorporation of telehealth visits, the utilization and capabilities of telemedicine continue to expand. A number of evidence-based resources are available to support medical providers to develop and utilize video evaluation for the sideline evaluation of sports-related injuries. Future research, including the development of validated, modified examination techniques and technologies, will allow for improved interactive physical examinations, which may be better utilized for sideline evaluation.

Introduction

In March 2020, sport in the United States was postponed or canceled in an effort to promote social distancing and prevent the spread of COVID-19. As competition began again, significant restrictions were imposed on the number of personnel allowed to be present at events, specifically on the sideline or field of play. The National Football League (NFL) banned cheerleaders, mascots, sideline reporters, and all on-field entertainment for the 2020 season [16]. Traveling parties were reduced from 110 individuals to a maximum of 70 non-player staff members [14]. Although the team physician has an integral role in the care of the injured athlete, new regulations may limit players’ access to multiple physicians and those with subspecialty training. Clinicians have been forced to think differently about how to provide care to new and existing patients. As a result, many are considering the use of telehealth evaluation on the sideline of professional sport.

Access to qualified medical personnel varies widely depending on the geographic location of an event, the level of competition, and the age of athletes. In more than 20,000 public and private secondary schools in the United States, 34% of schools had no access to athletic training services; of those with athletic trainers, 47% of schools had part-time coverage only [9]. The National Collegiate Athletic Association (NCAA) requires medical personnel trained in concussion management to be present on campus or at the arena during contact or collision sports, such as basketball, football, and ice hockey. For practice, the same medical personnel must be accessible at a minimum via “immediate communication means,” which can include telephone [12]. With travel and personnel restrictions due to COVID-19, the use of electronic communication between the athlete and the healthcare provider will likely increase.

Telemedicine uses audio and video technology to facilitate clinical care outside of the traditional setting. Historically, it was used to improve access to health care for patients in remote and rural areas or for patients who required specialty care. With the expansion of health laws and reimbursement for telemedicine visits during the COVID-19 pandemic, telehealth has an increasing presence in other domains of healthcare as well. The available technologies may affect all aspects of sports medicine, including prevention, management, and rehabilitation [21].

Telemedicine on the sideline has been primarily deployed for concussion evaluation, citing the success of tele-neurology services in guiding stroke care at limited-access hospitals. Prior to the COVID-19 pandemic, teams investigated the use of virtual neurotrauma experts to evaluate the concussed athlete and found high inter-rater reliability between the in-person and virtual providers [20]. Although virtual orthopedic examinations lack the important elements of palpation and dynamic testing, telemedicine may be expanded to sideline assessment of musculoskeletal injuries, although consideration must be given to protecting the athlete’s healthcare information, the need for specialized equipment, and the efficiency of assessment when making return-to-play decisions.

Given the current landscape of public health and sports medicine, we aim to provide a narrative review of the literature on the use of telemedicine on the sideline to evaluate acute concussion and orthopedic injury.

Sideline Medical Evaluation of Concussion and Illness

Using telehealth for the initial evaluation of the patient with suspected head injury was explored prior to the COVID-19 pandemic, as location and limited resources may hinder access to qualified clinicians who can perform initial examination of the concussed athlete. In the outpatient setting, there are numerous advantages to telehealth, including decreased travel time and cost, as well as limited use of office staff and overhead [8]. However, in sport, immediate sideline evaluation of head injury is required to make expeditious decisions about the athlete’s ability to return to competition; it also enables recognition of severe traumatic injury to the head or cervical spine [13]. Challenges associated with sideline evaluation include time constraints, ambient noise or distraction, and secondary motivation to return to play by the player and/or staff.

Northern Arizona University used a telemedicine robot over 2 consecutive football seasons, featuring a virtual neurologist who observed the face-to-face history and examination performed by on-site medical personnel. The study revealed that there were no significant differences in assessing the Standardized Assessment of Concussion, King-Devick test, or modified Balance Error Scoring System between virtual and on-site raters [20]. The authors note that while in-person evaluation is the gold standard, telehealth may be a feasible alternative. Benefits of trained sideline personnel include the ability to view the mechanism of injury in real time, perform nuanced or tactile physical exam maneuvers, recognize more severe injury requiring hospital transport, and prevent delays in treatment decisions. If only tele-concussion evaluation is available, efforts should be made to work with an affiliate physician who has treated the team before in order to promote familiarity in the interaction.

A study of pediatric concussion patients from northern Canada revealed that 80% were managed exclusively by telehealth through the duration of the study [8]. In this group, however, the median initial telehealth evaluation was 2 days from referral, which does not account for time from injury to referral. The results, while encouraging, are supportive of using telehealth in concussion follow-up and provide little guidance on sideline evaluation.

Telehealth is also indicated for use on the sideline for assessment of heat illness. Continuous core temperature monitoring is the gold standard in athletes suffering from heat exhaustion or heat stroke. Devices, such as ingestible capsules, have been designed to allow wireless monitoring of thermal strain and intestinal temperature [19]. Studies suggest that a rectal temperature is more reliable than ingestible devices; however, the prospect of remote monitoring of core temperature can allow the physician to help guide treatment decisions when not physically present.

In the outpatient primary care setting, telehealth was widely used to assess medical illness—such as respiratory or gastrointestinal symptoms—during the COVID-19 pandemic. In conditions unrelated to head injury, physicians can use telehealth to interview the athlete and to provide guidance on further testing or return-to-play decisions. For example, for the player with acute shortness of breath, sideline evaluation through telehealth can explore prior episodes of bronchoconstriction and effective treatments. The interview, coupled with vital signs if available, can provide valuable information for the clinician and the team. In the era of COVID-19, the decision to allow an athlete to return to activity must include consideration of potential infectiousness, disease transmission, and long-term outcomes for the affected athlete.

Crucial to the discussion of telehealth and sideline medicine is the availability of appropriately trained staff to administer testing and/or therapies. For concussion evaluation, staff must ensure that there is appropriate space to perform balance testing and a low-stimulus environment for cognitive testing. In conditions such as heat illness, the presence of a physician via telehealth does not preclude the necessity of preparation, such as measuring wet bulb globe temperature, having core thermometers, and cooling equipment (ie, ice water tub) available. A stable internet connection must be confirmed and periodically checked before and during competition. Regardless of the condition, the fundamental question lies in whether an athlete may return immediately to play, be held out and kept on site, or be transported for immediate evaluation. The telehealth clinician would be prudent to err on the side of caution if there is any uncertainty in the virtual assessment.

Sideline Evaluation of Musculoskeletal Injury

Telemedicine may continue to affect delivery of care for athletes with musculoskeletal injuries. Previous studies have explored the role of telemedicine in orthopedic consultations, and shown that it provides improved access, quality, and cost effectiveness in the evaluation for a variety of orthopedic conditions and procedures [1 –4,10]. A randomized controlled trial in Norway determined that video consultation for select orthopedic patients was safe, with no adverse events or difference in patient satisfaction in comparison with standard orthopedic visits [1]. It should be noted, however, that in this study, a trained nurse was present with the patients; also, patients were excluded if they were in need of advanced physical examinations (such as athletic knee or shoulder injuries). The accuracy of telehealth tools to determine pain, swelling, range of motion, strength, balance, and gait has been found to be valid, reliable, and feasible [5,11]. Prior studies have shown there is high agreement between in-person measurements and virtual evaluation of range of motion measurements and assessment of function for the shoulder, elbow, hip, and knee [15]. Furthermore, the use of telemedicine for orthopedic evaluation has been shown to be cost-effective, particularly when considering travel time for patients [1,10]. In one study, telemedicine encounters saved patients an average of 46 hours driving time and $1150 in travel-associated costs [10].

Despite the positive results of telemedicine in the orthopedic setting, very little research has assessed its specific use in the care of patients with sports medicine injuries. In an outpatient sports medicine practice, the majority of physicians and patients reported high satisfaction and value in the use of telemedicine for evaluation of musculoskeletal conditions, although this was not specific to acute evaluation of athletes and athletic injuries [18]. When considering benefits and preferences for athletes, telemedicine may provide a route to help athletes avoid missing class time and important team meetings and practice. Telehealth allows team athletic trainers to spend more time providing patient care rather than transporting athletes to clinic appointments, as well as improved efficiency for team physicians. During athletic competitions and/or on the sidelines, telehealth may help facilitate return-to-play decisions. In a sample of orthopedic team physicians and athletic trainers providing care to NCAA Division 1 athletes, providers found telemedicine was useful for initial evaluation, follow-up, and discharge encounters. The main advantages of this method were enhanced patient care, convenience of scheduling, and collaborative interprofessional relationship building [22].

Indication and Implementation of Telehealth Assessment

The need for remote sideline orthopedic evaluation exists when an athlete requires a musculoskeletal evaluation, but does not have access to these services in person. This could be due to remote geographical challenges, safety issues (such as a global pandemic), or when individual athletes or teams travel to training camps or athletic competitions without medical support staff. It is important to consider what can and cannot be accomplished in a telehealth context. Patients with complex or sensitive problems should be evaluated face-to-face [7].

Return-to-play is a decision-making process of allowing an injured or ill athlete to return to practice or competition. The goal is to clear an athlete for participation in sport without putting the athlete at undue risk for further injury or illness. Telehealth may be used as a tool for team physicians to help determine when an injured or ill athlete can return to practice or competition. For example, an athlete with a lateral ankle sprain can demonstrate range of motion and be observed performing functional movements such as heel- and toe-walking, jumping, squatting, and lateral cutting, to help determine if they are ready to return to sport. Decisions regarding return of an injured athlete can be a complex process and depends on the specific circumstances. Therefore, telehealth is not appropriate for all return-to-play decisions and should be used at the discretion of the medical team.

The implementation of telehealth services must be a collaborative effort between physicians, technology providers, athletes, coaches, and athletic trainers to design these services and gradually carry them out with appropriate support and education. A recent paper by Dijkstra et al. [6] provided detailed guiding principles for remote assessment of sports medicine patients. Authors highlight core ethical principles for telehealth services, including ensuring patient safety, using secure and effective communication methods, recommending appropriate treatment options, ensuring that patient feedback mechanisms are in place, and implementing strategies to evaluate and ensure patient satisfaction [6].

The Virtual Examination

Many musculoskeletal injuries and conditions require the physician to rely on examination findings to triage and manage injuries. Tanaka et al [17] discussed guidelines for telehealth visits to enable the clinician to best obtain the essential elements of an orthopedic examination. Prior to the visit, the authors recommend giving patients checklists to prepare for the visit. These lists should include specific instructions regarding the necessary clothing, lighting, setting, and camera and body positions that will allow for the visibility and examination of the affected body part. For sideline evaluation, physicians should communicate instructions to athletic trainers or other medical support staff present at the time of the evaluation, including examination methods for specific body regions such as the knee, shoulder, hip, and elbow. The virtual evaluation should include several key components. At the time of evaluation, a quick assessment including the athlete’s physical and mental function should be noted. Deformity, swelling, bleeding, and bruising should be observed. The involved and contralateral joint motion and strength should be assessed, as well as palpation of the injured area. Special tests should be considered based on the injury, which may be performed by the patient themselves versus an athletic trainer or other medical provider. Finally, the last component of the consultation is agreeing on a treatment plan, which may involve additional imaging or investigation, follow-up, referral, or further care. Following these guidelines will help optimize the quality and efficiency of the encounter [6].

Despite the documented success, there are recognized limitations in performing sideline physical examinations through telemedicine. The biggest concern is the inability to perform discrete palpation, provocative testing, and strength or stability examination. In addition, team physicians and athletic trainers must have collaborative relationships. In this model, for example, the athletic trainer can perform select tests and assessments as requested by the orthopedic team physician. How successfully these challenges are addressed will ultimately dictate how sports medicine providers begin to use telemedicine in sideline evaluation of injury.

Conclusion

In conclusion, with the rapid incorporation of telehealth visits, the use and capabilities of telemedicine continue to expand. The viability and cost-benefit analysis of telemedicine in sideline medical or musculoskeletal evaluation is currently lacking. Obtaining a thorough history and standardized assessment can increase the diagnostic value and quality of virtual evaluation. The telehealth provider must be aware of the ultimate disposition for the player evaluated on the sideline. If there is any uncertainty about the athlete’s ability to safely return to play after telehealth evaluation, the physician should feel empowered to defer the decision and recommend in-person care. A number of evidence-based resources are available to support team physicians, athletes, and other medical providers to develop and use video evaluation for the acute assessment. Future research includes the development of validated, modified examination techniques and technologies that will allow for improved interactive physical examinations. The expansion of telemedicine in sports medicine could provide a solution to improve injury prevention, management, and rehabilitation.