Teleconcussion - An Emerging Sports Concussion Management Model
The term “teleconcussion” refers to the use of telemedicine to treat concussions. The Department of Veteran’s Affairs (VA) Veteran’s Health Administration (VHA) has been using telemedicine successfully to treat soldiers with traumatic brain injury (TBI) since 2007. Using standardized, computerized TBI screening tests, personnel in the field assess injured soldiers and send the information they gather to neurologists to review and provide treatment recommendations. This model lends itself to high school sports, where coaches, trainers, and trained volunteers on the sidelines can administer computer-based assessments, send the results and baseline data to remote medical specialists, and initiate a video conference with the specialist – all in real time. The first published case study of this approach, which introduced the term “teleconcussion,” documents how telemedicine was used to treat a concussed soccer player in Arizona in 2013. Researchers in the field are hopeful that teleconcussion can address the limitations inherent in the current sports concussion management model: “As we seek new and innovative ways to provide the highest level of concussion care and expertise, we hope that teleconcussion can meet this need and give athletes at all levels immediate access to concussion experts.”
- 1 Context
- 2 Concussion Basics
- 3 Limitations of Current Concussion Management Approaches
- 4 Components of a Teleconcussion Solution
- 5 Research Studies and Pilot Programs
- 6 Relevant Legislation
- 7 Advantages of the Teleconcussion Model
- 8 References
Around the country, high school football games have been forfeited and, in some cases, entire seasons cancelled because schools cannot field enough healthy players and school officials are concerned about injuries, particularly concussions. Against this backdrop, sports governing bodies from the NFL to the National Federation of State High School Associations (NFSHSA) have recognized the need to take action to improve concussion management. The difference between the NFL and the NFSHSA, however, is that while the NFL has financial and medical resources, including trained sideline physicians, to allocate to this issue, many high schools are geographically removed from specialized medical care and depend on community volunteers to perform sideline concussion assessments. In fact, only 42% of high schools in the United States have an athletic trainer.  Teleconcussion offers a potential solution. Video conferencing technology can connect trainers, coaches, parents, and injured players on the sidelines to neurology specialists who can help assess possible concussions and collaborate to make decisions about whether or not players should return to play.
The fact that developing brains appear to be more vulnerable to concussions increases the urgency of addressing the concussion problem at the youth level. Dr. Bert Vargas, of the Mayo Clinic, highlights the possibility that telemedicine might be an important part of this effort: “It is amateur and youth athletes who are more susceptible to concussion and its aftereffects (compared to professional athletes) but have the fewest resources to identify, evaluate, and manage concussion. This disparity in access to health care also suggests that an important niche may exist for the use of telemedicine in sports.”
The Centers for Disease Control and Prevention (CDC) defines a concussion as follows: “a type of traumatic brain injury, caused by a bump, blow, or jolt to the head. Concussions can also occur from a blow to the body that causes the head and brain to move rapidly back and forth – literally causing the brain to bounce around and twist within the skull. This sudden movement of the brain causes stretching and tearing of brain cells, damaging the cells and creating chemical changes in the brain.” Although they are classified as mild traumatic brain injuries, concussions are a serious health problem, particularly for young people who participate in contact sports. According to the American Association of Neurologic Surgeons, approximately 300,000 athletes suffer concussions in the United States each year, 62,000 of whom are high school students. One in four athletes participating in a contact sport will suffer a concussion at some point in his or her career; among college football players, the percentage rises to 34%, with 20% of those who participate in college football reporting multiple concussions.   The figures reported by the National Center for Injury Prevention are even more alarming: 47% of boys who play high school football are diagnosed with a concussion every year, and 35% report multiple concussions in one season.
Taking into account that many concussions go unreported (as many as 85%, according to an American College of Sports Medicine estimate), these statistics are even more concerning. If symptoms go unnoticed or unreported, or concussion evaluation is inadequate, athletes may be cleared to return to activity too soon, which increases the risk of a second concussion. “Sudden impact syndrome,” which occurs when a person who is recovering from a concussion has another concussion before fully recovering from the first, can be fatal. Athletes who suffer concussions may seem fine initially, but over time symptoms such as confusion, headaches, irritability, sensitivity to light or noise, depression, and concentration problems may appear.   Young athletes are particularly vulnerable for a number of reasons. Young brains are more affected by the forces applied during a concussion and require a longer recovery time than older brains.  Young people are also more prone to repeat concussions and persistent neurological symptoms. Concussion symptoms typically last 7-10 days but may persist for several weeks in young athletes. Per Dr. David Dodick of the Mayo Clinic: “The developing brain appears to be more vulnerable to the shear and strain forces placed on the brain during a concussion. We have seen many young people who have had a decline in academic performance that persists more commonly after repeat concussions, but sometimes after a single concussion.”
Limitations of Current Concussion Management Approaches
Currently all 50 states require that a high school athlete who exhibits concussion symptoms be removed from play and cleared by a medical professional before returning to normal activity. In support of this requirement, the CDC has implemented a concussion awareness campaign that includes a “Heads Up Four-Step Action Plan” for coaches and trainers to follow if they suspect an athlete has been concussed. The four steps are: 1) Remove the athlete from play, 2) Have the athlete evaluated by the appropriate healthcare professional, 3) Inform the athlete’s parents, and 4) Keep the athlete out of play until he or she is medically cleared to return. The CDC literature also lists symptoms for which coaches should watch – both those that they observe (such as an athlete appearing dazed, moving clumsily, or answering questions slowly) and those that the athlete reports (such as headache, nausea, or dizziness). In addition, the CDC documents a gradual five-stage approach for returning an athlete to play, with repeated warnings that if concussion symptoms recur at any stage, the athlete should be moved back to the previous stage and re-evaluated by a healthcare professional. The motto of this approach is “When in doubt, sit them out.”
While this approach is effective in theory, in practice it is limited both in terms of the initial concussion assessment and the medical follow-up. Coaches and trainers are not able to observe every player on the field, and often athletes are reluctant to report concussion symptoms because they don’t want to be removed from the game and face the possibility of sitting out for a couple of weeks until they are cleared to return. Helmets with sensors that light up when a player’s head is struck have been marketed as an aid to spotting football players who may have been concussed, but recent news stories suggest that this approach is not reliable. During the 2015 season, a high school football player in California was hospitalized (and remains in a coma) after a hard hit; his helmet sensor did not register the hit. Even when coaches are able to spot potentially concussed athletes, in many areas of the country medical professionals with concussion expertise are not readily available to assess and clear the players. This leaves the concussion assessment to coaches, trainers, and volunteer health professionals, none of whom have adequate training.
Components of a Teleconcussion Solution
A teleconcussion solution for sports includes the following components: baselining and sideline assessment (using standardized, computer-based concussion assessment tests); spotters (human and robotic); and video conferencing with medical specialists.
Baselining and Sideline Assessment
Baselining refers to measurements taken at the beginning of a sports season. This initial assessment is crucial because it provides a benchmark against which a post-injury sideline assessment can be compared. Widely-used concussion assessment tests include:
- The Standardized Assessment of Concussion (SAC) evaluates orientation (ability to correctly identify the current day, month, and year), immediate recall (ability to remember five words three separate times), and physical ability (ability to perform exercises such as jumping jacks).).
- The King-Devick (KD) evaluates rapid eye movement using a timed reading of increasingly difficult numbers and digits.).
- The modified Balance Error Scoring System (mBESS) evaluates balance using three exercises (also performed while standing on a piece of foam in the non-modified version of the test).
- The SCAT 3, released in 2013, is the latest version of a comprehensive suite of tests developed by a panel of experts at an international meeting on concussion in sports. It includes an evaluation of player symptoms and signs; balance and coordination tests; Glasgow Coma Sign (GCS) evaluation (testing, also used to assess coma patients, that assigns scores for eye movement, verbal response, and motor response); a battery of sideline assessment questions; and the SAC tests.
Standardized, computer-based assessment tests represent an advance over manual tests used in the past for a variety of reasons. The new tests provide finer granularity of measurement; they feature large lists of questions so players cannot memorize answers in an attempt to beat the system and return to play when they are impaired; and they provide immediate results and comparisons with baseline scores. New York University's Langone Medical Center is also conducting a study involving a “Concussion Tracker” app that records user answers to daily survey questions about balance, vision, and results of concentration and walk tests during the six weeks following a concussion.
In the teleconcussion model, when a player suffers a potential concussion, sideline personnel perform an assessment (entering the results on tablets or other personal computing devices) and immediately send both the baseline and post-injury data to a medically-licensed concussion specialist for evaluation. Before they know to evaluate a player, however, the sideline personnel must be able to spot potential head injuries. The NFL employs head injury spotters. These spotters are experienced, specially-trained athletic trainers who sit in the booth above the stadium, use video monitors to analyze plays involving potential head injury, and communicate directly with sideline doctors and trainers via cell phone or walkie-talkie. The sideline personnel then initiate a video teleconference with an independent neurologist and put identified players through concussion assessment tests, recording the results on tablets. While professional spotters may not be available at most high schools, this model could be used in a high school setting with trained volunteer spotters.
Robotic spotters are also being tested. The VGo robot, developed at Dartmouth College, is controlled remotely by a trained spotter (ideally a neurologist), who can respond to a hard hit or potential head injury by initiating an interactive video telemedicine session with sideline personnel and the player. Using this approach, the remote neurologist can view a live broadcast from a perspective that includes the ability to rewind and slow down the video and zoom in and track a particular player as necessary. This perspective provides a “big picture” not available to sideline personnel.
In addition, while helmet sensors have not proven to be reliable as concussion-spotting tools, a skull cap sensor worn under helmets appears promising. This device, called the CheckLight and developed by Reebok in conjunction with MC10, measures direct accelerations to the head rather than to the helmet or chinstrap and provides both linear and rotational measurements.  This is significant because a concussion exerts both linear and rotational forces on the brain. The CheckLight cap lights yellow or red depending on the severity of the impact and signals a spotter or trainer to bring the player to the sideline for evaluation.  The device won the International Consumer Electronics Show (CES) Innovations 2014 Design and Engineering Award.
The final piece of a teleconcussion solution is videoconferencing with remote healthcare professionals. Made possible by increased availability of 3G, 4G, and wireless networks, videoconferencing allows a person on the sidelines to interact in real time with a neurologist, who can both help to assess the injured player and provide treatment and return-to-play recommendations. The remote neurologist is also available for subsequent follow-up care. Instead of sitting out for the season as a precaution because untrained coaches and trainers are in doubt about their medical status, players can be evaluated immediately and their care can be managed by a concussion specialist. This approach is particularly valuable in a high school setting, where sideline medical personnel are often volunteer physicians who are not trained in concussion assessment, and where students are often geographically isolated from comprehensive concussion care centers. 
Research Studies and Pilot Programs
Research studies and pilot programs at both college and high school levels seek to test the effectiveness of the teleconcussion model and provide impetus for more widespread adoption.
A study conducted by the Mayo Clinic in Phoenix, in conjunction with Northern Arizona University, ran for the 2013 and 2014 football seasons. For the study, baselines were established for all football players using three standard concussion assessment tests (the SAC, the KD, and the mBESS). During games (both home and away), a sideline (VGo) robot provided video feed to a remote neurologist, who evaluated injured players for concussions using the same tests.   In addition, trainers and team doctors performed onsite evaluations of the same players. The study compared the concussion assessments performed by the remote neurologist and robotic spotter to those performed by onsite trainers and doctors and found them to be almost identical. The mean difference in KD test times was 0.7 seconds; mBESS scores were within 3 points 100% of the time; and remove from or return-to-play decisions were 100% in agreement.  The model was tested in Phoenix-area high schools during the 2015 football season.
In Mississippi, a project launched in August 2015 by the University of Mississippi Medical Center (UMMC), using technology provided by Dell and Vsee, connects UMMC concussion specialists to the football sideline at 11 rural high schools. The connection is made via the Internet using Windows tablets running Health Insurance Portability and Accountability Act (HIPAA)-compliant software with built-in cameras.  Two people at each high school were trained by UMMC to use the teleconcussion system and perform baseline tests using the SCAT 3 suite. When a player is injured, one of these two people assesses the player using the SCAT 3 tests. They then send the information to a UMMC physician who assesses the injury and the player’s return to play readiness using the test data as well as an interactive video consult involving the sideline assessor and the player.  The UMMC physician remains “on call” until a couple of hours after each game so players can be evaluated after the game ends as necessary.9 The UMMC Center for Telehealth, which is coordinating the program, plans to help 10-20 other hospitals in Mississippi implement teleconcussion programs to support local high schools.  The program will also be evaluated after the end of the season and results will be reported to the NFSHSA, which may expand it to other states if the program proves to be successful.
One barrier to teleconcussion is the issue of state medical licensing. Physicians are licensed to practice medicine on a state-by-state basis. Under the current legislation, a doctor can only practice telemedicine on patients located in the same state. In order for doctor licensed in Oregon to practice telemedicine on an injured football player in rural Idaho, for example, the doctor would need to obtain an Idaho medical license. The Interstate Medical License Compact addresses this issue by expediting the process for getting a license to practice medicine in another state. As of this writing, 12 states have joined the compact, 14 other state legislatures are considering joining, and the compact has been endorsed by 30 state medical boards. Other pending legislation includes the TELE-MED Act, which would allow providers in all 50 states to treat Medicare patients in any state with a single license, the only requirements being that the provider participates in Medicare and the recipient of care is a Medicare beneficiary. In addition, the Telehealth Enhancement Act of 2015 would expand covered telehealth originating sites to include home telehealth sites as well as urban critical care hospitals and sole community hospitals.  The bipartisan Medicare Telehealth Parity Act of 2015, which deals with Medicare reimbursement, proposes a phased approach to extend telehealth coverage to both rural and urban areas and to allow telehealth visits to be reimbursed as though they were in-person visits. This proposed legislation has not yet passed out of committee and it may not affect teleconcussion implemented to manage sports-related concussions in all cases, but it “removes some geographic barriers by allowing providers to engage in telehealth services in rural, underserved, and metropolitan areas.”
Advantages of the Teleconcussion Model
Telemedicine in general provides underserved populations with access to health care; teleconcussion in particular provides undertrained sideline personnel with resources to improve concussion management for young athletes. The need for these resources cannot be understated. “Statistics on NCAA.org show that only 0.08 percent of high school football players will make it to the NFL, whereas every single high school football player could suffer some form of irreversible brain damage.” Although the number of high school students participating in football declined by 17,000 (approximately 2%) between 2008 and 2013, football is still the most popular high school sport, with approximately 1.1 million participants each year. Teleconcussion cannot protect these 1.1 million football players from concussions, but it can provide a virtual sideline doctor to help coaches and trainers manage their concussions more safely.
Teleconcussion allows athletes who might not otherwise have access to specialized care to be treated in a timely fashion (immediately post-injury on the sideline) and to be cleared to return to play or kept out of play based on objective data analyzed by a concussion specialist. In addition, in cases where an athlete is unable to travel to a specialist’s office or there are no neurological specialists within a reasonable distance, teleconcussion offers a promising solution for follow-up care.
Without the baselined and standardized assessment tools central to the teleconcussion model, the burden is on coaches, trainers, and parents to spot potential concussions and on players to self-report. In a sports culture that often values winning at all costs, this can be a tall order for a high school athlete: The teleconcussion model removes the burden of self-reporting and replaces evaluation performed by people who may have interests other than a player’s long-term health with analysis of data by medical experts. Spotters identify players for evaluation, and standardized, scored tests provide data which is analyzed by remote (and objective) healthcare specialists. This approach leaves no room for argument from players, or from coaches or parents who might want a star player to return to play based on subjective reporting of concussion symptoms but cannot argue with objective, medically-vetted data. The model could easily be extended from high school football to other sports, such as girls’ soccer. If the results from pilot programs support the promise of teleconcussion, the virtual sideline doctor that this model of care introduces may soon be a regular fixture on youth sports sidelines.
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Submitted by Leslie DeYoung