Fifteen-year-old soccer player and snowboarder Seth is no stranger to competition. But with a coach for a father and two athletic older brothers, this high school sophomore is well aware of the dangers of concussion. He had to learn the lesson firsthand when, playing against a rival school one night, as he and his opponent both rushed to gain control of the ball, Seth sustained a kick to the head and was knocked unconscious. He was removed from play and did not respond to any commands or questions until he got to the local emergency department at Summit Hospital in Show Low, AZ, for basic observation, where he began, slowly, to form replies. But his symptoms of headache, dysequilibrium, trouble concentrating and sleeping persisted.
The hospital in Show Low — a rural community of about 12,000 people — is a nearly four-hour drive from the nearest neurological center and comprehensive concussion program, located at Mayo Clinic in Phoenix, AZ. Four hours, when it comes to concussion treatment, can be a critical care window. And because of a new Arizona law (Senate bill 1521) — which mandates that all concussed athletes be removed from play immediately and cleared by a licensed health-care provider before returning to the game — this distance seems especially significant. The neurologists at Mayo Clinic were concerned that this mandate might create considerable barriers specifically for rural student athletes, where there may be an insufficient number of licensed professionals trained in concussion evaluation and management.
Without access to specialists, in rural areas like Show Low, many “athletes slip through the cracks, and return to sports prematurely — placing themselves at risk for recurrent concussion, prolonged concussion symptoms and signs, or worse — death,” Bart Demaerschalk, MD, and Bert Vargas, MD, neurologists from Mayo Clinic in Phoenix, AZ, told Neurology Today.
Dr. Demaerschalk professor of neurology, and director of the Cerebrovascular Diseases Center and the Teleneurology and Telestroke Program at Mayo Clinic, told Neurology Today: “Since these communities are at a disadvantage, telemedicine may help to bridge that gap in access to specialty concussion care.”
The program is still at a pilot stage, said Dr. Vargas, assistant professor in the department of neurology at Mayo Clinic said. The focus during this initial period is on the community of Show Low. Along with Philip Johnson, MD, who is medical director and chair of emergency medicine at Summit Healthcare, Mayo Clinic neurologists are figuring out the best methods of providing expert concussion guidance to rural athletes using the medium of telemedicine.
Dr. Vargas said, presently, when athletes are removed from play, they have to be evaluated by a trained healthcare provider — and that can be anyone, including athletic trainers, primary care physicians, as long as they are equipped to evaluate the concussion. “However, some of the [concussion] cases are in those gray zones where either some of these experts need additional help with or the opinion of a neurologist may be to support their diagnosis. This [program] is making it possible for rural communities to access the same care that people would in large metropolitan areas, like Phoenix or Tucson.”
HOW DOES IT WORK?
The teleconcussion program is staffed by Mayo Clinic teleneurologists 24 hours-a-day, 365 days-a-year, for emergency assessments of traumatic brain injury, Dr. Demaerschalk said. Following the emergency assessment, the youth athlete undergoes a scheduled follow-up teleconcussion assessment with one of four designated sports concussion neurology specialists.
Mayo Clinic is using a mobile telemedicine cart, equipped with a camera and microphone/speaker to establish a remote connection between doctor and patient. On our end, said Dr. Demaerschalk, we need a desktop or laptop computer with internet connection. “We can access the telemedicine carts that are situated in the hospitals or clinic environments, but what we anticipate researching is other telemedicine modalities,” he said, such as the FaceTime feature on iPhones (which is already the subject of an IRB-approved Mayo Clinic telestroke research study).
“In the span of just about the length of a standard clinic visit, we are able to see this patient live, perform the neurological exam, review their cognitive testing remotely, look at their brain imaging studies, and then make a recommendation,” said Dr. Vargas.
After the pilot stage, Dr. Demaerschalk said, we hope to provide even pre-hospital or “field-side” assessments using devices such as iPhones and iPads and portable telemedicine equipment, in order to begin assessments immediately at the time of head injury and then follow up with appropriate clinic setting telemedicine evaluations as well.
CANDIDATES FOR TELECONCUSSION
“The types of patients we would screen for a face-to-face assessment,” Dr. Demaerschalk said, “would be patients who have prolonged, persistent, or recurrent concussion symptoms; the patients that would be in need, for example, of any number of brain imaging evaluations beyond a CT scan — an MRI scan, diffusion tensor imaging tractography, SPECT scanning, whether they also may need vestibular evaluations.”
So far, the teleconcussion program has been used to assess one soccer player and one football player. Both presented to the local emergency department for a clinical examination and a CT scan of the head, the emergency physician then consulted Mayo Clinic neurology department for a teleconcussion evaluation which followed over the next several days, said Dr. Demaerschalk.
One challenge with treating a patient remotely, both neurologists agreed, is the lack of knowledge of the athlete's pre-concussion neurological and cognitive state that could help measure the individual's deviation from baseline. However, the physicians were able to interpret the patients' self-reports and “subtle examination clues.”
We've learned that concussion translates very well to a telemedicine platform, said Dr. Vargas. The problem, he said, is that we haven't yet validated this medium to clear a patient to return to play. Although it's most likely very effective, that's not really what we're using the teleconcussion program for. “Right now, this program is extremely effective in helping to support the diagnostic impressions of local emergency department and primary physicians. It is also helpful in identifying patients who clearly need further specialty workup. The biggest challenge will be providing supporting data from our studies to validate telemedicine as an accurate means by which to safely return athletes to play,” the Mayo neurologists said.
During this pilot, we will compare the effectiveness of the audio video teleconcussion assessment with a face-to-face assessment by similarly trained and qualified concussion neurologists, said Dr. Demaerschalk. “We'd also like to test the reliability and validity of a teleconcussion assessment in prospective evaluation to determine whether our rules and algorithms can result in safe and effective decisions to return to play and school.”
AAN SPORTS CONCUSSION TOOLKIT
The AAN has created an online portal for physicians, athletes, coaches, trainers, and parents to become experts in recognizing signs of concussion. Visit aan.com/concussion to view articles, online trainings, official guidelines, as well as other resources — all part of the AAN Sports Concussion Toolkit. Featured are two free online safety courses created by the University of Michigan Neurosport program and endorsed by the AAN to help coaches recognize concussion signs and the consecutive steps to take after head injury is identified. Each 20-minute safety course is free and a printable certificate is available after passing the online quiz.
IS TELECONCUSSION COST-EFFECTIVE?
Given the broad infrastructure of telemedicine programs already at Mayo Clinic, the teleconcussion program will serve as merely an addition — albeit an important one — to an already existing network of telemedicine facilities, experts at Mayo Clinic told Neurology Today.
Currently, the Mayo Clinic teleneurology network consists of a hub hospital, in Phoenix, and ten participating rural spoke hospitals in the state. “We are already providing telestroke and teleneurohospitalist care to these spoke hospitals, and we're proposing to add a teleconcussion service to the teleneurology network,” said Dr. Demaerschalk. The remote spoke hospitals are as close as within 100 miles of Phoenix but are as far away as 500 miles away from Phoenix.
There are approximately 27 remote or rurally located hospitals within the state of Arizona — and we plan to systematically expand the teleneurology — and therefore the teleconcussion — network to include every community in the state outside of large metropolitan regions, said Dr. Demaerschalk.
Probably where teleconcussion is the most cost-effective, Dr. Vargas added, is that some of these individuals are getting the evaluations and additional follow-up care that they may not have otherwise received. “So, that's a more implicit benefit — that we're hopefully safeguarding the brains of our rural student athletes,” said Dr. Vargas.