15.1

Considerations for a Virtual Medical Assessment.

See Recommendation 2.1 “Physicians or nurse practitioners should perform a comprehensive medical assessment on all children/adolescents with a suspected concussion or with acute head or spine trauma.
• Include a clinical history, physical examination, and the evidence-based use of diagnostic tests or imaging as needed.”

In-person medical assessments are ideal for all children/adolescents with suspected or diagnosed concussion, however, telemedicine may be considered to assist in the medical assessment for patients who meet the following criteria:
• A previous medical assessment by a physician or nurse practitioner has been performed.
• Access or travel for an in-person medical assessment is limited or difficult
• There is no history of abnormal diagnostic imaging (e.g., intracranial hemorrhage, spine or facial fracture)

Note: All providers should be aware of current public health recommendations when providing care to their patients.

Tool 15.1: Considerations for telemedicine and virtual care algorithm

Level of Evidence:  

15.1a

Obtain informed consent from the patient and/or their parent/caregiver to conduct a remote medical assessment via telemedicine.

This process should outline the benefits and limitations of performing clinical care via telemedicine as well as taking measures to ensure privacy and confidentiality. Discuss the important limitation of not being able to perform some aspects of the physical examination virtually (e.g., testing of motor or sensory functioning, fundoscopy, etc.) and outline what arrangements will be made to facilitate an urgent in-person assessment as needed to optimize clinical care.

For other general considerations on how clinicians and patients can be prepared for a virtual visit see the following links:

• Canadian Medical Association. Scaling up virtual care in Canada: CMA a key player in new national task force. February 2020. https://www.cma.ca/scaling-virtual-care-canada-cma-key-player-new-national-task-force
• American Medical Association.TeleHealth Quick Guide September 2020.
• Canadian Medical Association. Virtual Care Guide for Patients. June 2020.

Level of Evidence:  

15.1b

Take a comprehensive virtual clinical history.

Complete a comprehensive virtual clinical history that addresses the same key components of an in-person medical assessment including patient demographics, injury mechanism, symptoms at the time of injury, symptom burden at the time of presentation, loss of consciousness, post-traumatic amnesia, self-reported red flags, mental health, past medical history, assessment of concussion modifiers, current medications and allergies, school, work, and sports participation.

• See Recommendation 2.1a for details that should be collected in the clinical history. This recommendation includes a validated age-appropriate symptom inventory that can be considered as a tool to assess current symptoms and severity.

Level of Evidence:   

15.1c

See Recommendation 2.b “Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.”

15.1d

Considerations for a virtual physical assessment

A virtual physical examination should aim to assess similar aspects of neurological functioning evaluated during an in-person medical assessment with modifications based on the presence of a remote telepresenter or examiner.

• The unassisted virtual physical examination should include assessment of mental status, speech, cranial nerves, coordination, balance, gait, cognitive functioning, oculomotor functioning, and the cervical spine.
• Certain aspects of the physical examination including assessment of motor, sensory and vestibular functioning; palpation and provocative testing of the cervical spine; testing of visual acuity and deep tendon reflexes; as well as fundoscopic and otoscopic examinations cannot be performed virtually.

Tool 15.2: Considerations for a virtual physical examination for medical assessment and follow-up of concussion patients

Tool 15.3: Virtual Care Exam Training Resource. A training manual to assist front-line healthcare professionals who are caring for patients that cannot be seen in person or have already had an in-person assessment and require follow-up.

Level of Evidence:  

15.1e

Considerations for a virtual physical examination for medical assessment and follow-up of concussion patients

Link: Recommendation 2.1c -recommendations on an in-person medical assessment.

Level of Evidence:  

15.1f

Recommendation 2.1c: “Consider CT of the brain or cervical spine only in patients whom, after a medical assessment, a structural intracranial or cervical spine injury is suspected; do not conduct routine neuroimaging for the purpose of diagnosing concussion.” 

15.2

Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/driving/work and strategies to promote recovery.

This should include the following:

• Guidance on the appropriate use of rest and guidance on making a gradual return to symptom-limiting cognitive, school, social, and low-risk physical activities.
  • Recommendation 2.3 Recommend graduated return to cognitive and physical activity to promote recovery.
  • Domain 12: Return to school
• Guidance on sleep (Recommendation 2.4 a)
• Recommendation on social networks and interactions (Recommendation 2.4b)
• Recommendation on driving (Recommendation 2.4e)
• Guidance on the appropriate use of over-the-counter medications for symptom management (Recommendation 2.5)
• Recommendation on screen time and electronic device use (Recommendation 2.4c)
• Recommendation to avoid alcohol and recreational drugs (Recommendation 2.4d)

Where available, provide post-injury education that is appropriate for the patient’s culture and/or preferred language.

Summary of online tools to consider related to lifestyle strategies and expectations:

• Link: Tool 2.6: Post-Concussion Information Sheet 
• Link: Advice for gradually resuming intellectual, physical and sports activities English/ French(INESSS)
• Link: After a Concussion: Return to Sport Strategy(Parachute Canada)
• Link: HEADS UP Resources for Returning to School(CDC)
• Link: Return to Activity Strategy(CATT)
• Link: Return-to-School Strategy(CATT)
• Link: Return to Sport Strategy(CATT)
• Link: Return to School Strategy(Parachute)
• Link: Post Concussion Information Sheet for First Nations Youth (Parachute)
• Link: Post Concussion Information Sheet for Nunavut Youth – French (Parachute)
• Link: Post Concussion Information Sheet for Nunavut Youth – English (Parachute)
• Link: Post Concussion Information Sheet for Nunavut Youth – Inuktitut (Parachute)
• Link: Post Concussion Information Sheet for Nunavut Youth – Inuinnaqtun (Parachute)

Level of Evidence:  

15.3

Provide a written (electronic) medical assessment or clearance letter to the child/adolescent and the parent/caregiver.

Link: Canadian Guideline on Concussion in Sport Medical Assessment Letter

Link: Canadian Guideline on Concussion in Sport Medical Clearance Letter

Level of Evidence:  

15.4

Provide a medical follow-up assessment on children/adolescents with concussion in 1-2 weeks to re-assess and monitor clinical status. A regular medical follow-up is also recommended if a child/adolescent is still experiencing post-concussion symptoms or has not completed the return-to-school or return-to-sport/activity stages. Recommend immediate in-person medical attention in the presence of any deterioration.

While in-person medical follow-up is ideal, telemedicine (e.g., real-time in-person videoconferencing) may be considered for follow-up appointments for the following patients with concussion:

1. Those for whom access or travel for follow-up is limited or unavailable such as those who live in rural and remote communities.
2. Those who have undergone a previous in-person medical assessment by the treating physician or nurse practitioner
3. Those whose symptoms are stable, improving, or resolved
4. Those who do not report any subjective red flags (e.g., blurred or double vision, weakness or numbness, vertigo) and who have a satisfactory virtual physical examination with no objective red flags (e.g., diplopia on extraocular movement testing, positive pronator drift, pain on testing of cervical spine range of motion)
5. Those who do not require supplemental testing (diagnostic imaging, neuropsychological testing, graded aerobic exercise testing), and/or inter-disciplinary referrals to optimize patient care

Tool 15.1: Considerations for telemedicine and virtual care algorithm

Level of Evidence:  

Please refer to Domain 3: Medical follow-up and Management of Prolonged Symptoms for a full list of clinical guideline recommendations to consider when performing a medical follow-up assessment and managing prolonged concussion symptoms.

15.5

Please refer to Domain 4: Medical Clearance for full-contact sports and high-risk activities for a full list of clinical recommendations to consider when determining if a child/adolescent is ready to return to full-contact sports or high-risk activities. Medical clearance is not required to return to school.

15.6

Recommendations for inter-disciplinary healthcare professionals involved in the care of concussion patients:

Neuropsychologists

Virtual care may be considered to assist in the assessment and longitudinal care of concussion patients who develop persistent cognitive and mood-related symptoms or who are having persistent problems in school. Neuropsychologists should be aware of the limitations of performing certain neuropsychological tests via in-person videoconferencing. Specific symptom assessments can be administered virtually or completed before the virtual appointment and sent to the neuropsychologist ahead of time.

Level of Evidence:  

Physiotherapists

Virtual care may be considered by physiotherapists to advance vestibular, cervical spine and medically supervised individually tailored sub-symptom threshold aerobic exercise treatment plans in patients who have undergone previous in-person assessment by the treating physiotherapist. Physiotherapists should recognize that a comprehensive assessment of the cervical spine and vestibular system as well as graded aerobic exercise testing, which are required to provide initial recommendations regarding targeted rehabilitation, cannot be performed virtually. If a physiotherapist is providing virtual care, they must be able to arrange an urgent in-person assessment as needed.

Level of Evidence:  

• See link for general information on telerehabilitation: TR-Telerehab Toolkit: https://kite-uhn.com/tools/tr-telerehab-toolkit
• Alberta Physiotherapy: Telerehabilitation Resource Guide https://www.physiotherapyalberta.ca/files/guide_telerehabilitation.pdf

Psychiatrists

Telemedicine may be considered to assist in the assessment and longitudinal care of concussion patients who develop persistent psychiatric and sleep-related symptoms and disorders.

Level of Evidence:  

Headache neurologists

Telemedicine may be considered to assist in the assessment and longitudinal care of concussion patients who develop persistent headaches.

Level of Evidence:  

Occupational therapists

Virtual care may be considered to assist in the assessment and longitudinal care of concussion patients who develop prolonged cognitive and mood-related symptoms and to assist with a successful return to school and other activities of daily living.

Level of Evidence: