Telemedicine and Virtual Concussion Care

Section D:


icon img Telemedicine and Virtual Concussion Care


Preliminary research has demonstrated that telemedicine can be used to provide timely access to safe and cost-effective medical care of carefully selected concussion patients living in underserved regions. Research from the teleneurology, telepsychiatry and teleneuropsychology literature suggests that patients with prolonged concussion symptoms including those with headaches, mental health disorders, and cognitive impairment may also benefit from accessing care via telemedicine. While the COVID-19 pandemic has propelled greater use of virtual care, healthcare professionals using virtual platforms to deliver concussion care should be aware of the limitations of these approaches in order to ensure they are practicing in accordance with regional guidelines and policies outlined by their respective professional regulatory bodies. The future use of telemedicine and virtual care to assist in delivering primary and interdisciplinary concussion care will continue to be refined by future research and experience.


Telemedicine: Telemedicine has been defined as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.” (WHO, 2010). Telemedicine can be delivered synchronously (e.g., in-person videoconferencing) or asynchronously (e.g., store and forward or EConsultation).

Virtual care: Virtual care has been defined as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care” (Shaw et al, 2018).

The following clinical recommendations and preliminary algorithm have been developed to share evidence and expert opinion on how to guide the medical and interdisciplinary care of pediatric concussion patients using telemedicine and include suggestions to optimize a virtual medical assessment.


LEVEL OF EVIDENCE A = Consistent, good-quality, patient-oriented evidence (example: at least one large randomized control trial, meta-analysis or systematic review with homogeneity, or large, high- quality, multi-centre cohort study)B = Inconsistent or limited-quality patient-oriented evidence (example: smaller cohort studies, case studies or control trials with limitations)C = Consensus, usual practice, opinion or weaker-level evidence


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:  


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:

Level of Evidence:  


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:   


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


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:  


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:  


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.” 


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:

Level of Evidence:  


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:  


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.


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.


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


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:  



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:  



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:  

Tools and Resources

General guidelines and tools related to telemedicine and virtual care

Canadian Medical Association. Scaling up virtual care in Canada: CMA a key player in new national task force. February 2020.

Canadian Medical Association. Virtual care guide for patients. June 2020.

Shaw J, Jamieson T, Agarwal P, et al. Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique. J Telemed Telecare 2017;0(0):1–8. 2 Federation of Medical Regulatory Authorities of Canada. FMRAC framework on telemedicine. Available:

TR-Telerehab Toolkit:

World Health Organization. Report on the second global survey on eHealth. 2010.

Wechsler LR, Tsao JW, Levine SR, Swain-Eng RJ, Adams RJ, Demaerschalk BM, et al. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology. 2013;80(7):670-6.


Articles related to medical assessment and management

Ellis MJ, Boles S, Derksen V, Dawyduk B, Amadu A, Stelmack K, et al. Evaluation of a pilot paediatric concussion telemedicine programme for northern communities in Manitoba. International Journal of Circumpolar Health. 2019;78(1):1573163.

Ellis MJ, Russell K. The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada. Frontiers in Neurology. 2019;10:840.

Ellis M, Mendez, Russell K. (2020). Preliminary clinical algorithm to optimize delivery of remote pediatric concussion care in Canada’s North. International Journal of Circumpolar Health (published online October 22, 2020)

Vargas BB, Channer DD, Dodick DW, Demaerschalk BM. Teleconcussion: an innovative approach to screening, diagnosis, and management of mild traumatic brain injury. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2012;18(10):803-6.

Blue R et al.: Telemedicine in the era of coronavirus disease 2019 (COVID-10): a neurosurgical perspective. World Neurosurg 2020; 139; 549-557

Vargas BB, Shepard M, Hentz JG, Kutyreff C, Hershey LG, Starling AJ. Feasibility and accuracy of teleconcussion for acute evaluation of suspected concussion. Neurology. 2017;88(16):1580-3.

Wechsler LR. Advantages and limitations of teleneurology. JAMA neurology. 2015;72(3):349-54.

Wechsler LR, Tsao JW, Levine SR, Swain-Eng RJ, Adams RJ, Demaerschalk BM, et al. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology. 2013;80(7):670-6.

Vierhile A, Tuttle J, Adams H, tenHoopen C, Baylor E. Feasibility of Providing Pediatric Neurology Telemedicine Care to Youth with Headache. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners. 2018;32(5):500-6.


Articles related to telepsychiatry

Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World journal of psychiatry. 2016;6(2):269-82.

Nelson EL, Cain S, Sharp S. Considerations for Conducting Telemental Health with Children and Adolescents. Child and adolescent psychiatric clinics of North America. 2017;26(1):77-91.

Roth DE, Ramtekkar U, Zekovic-Roth S. Telepsychiatry: A New Treatment Venue for Pediatric Depression. Child and adolescent psychiatric clinics of North America. 2019;28(3):377-95.


Articles related to general tele-neuropsychology practice

Bilder RM et al. (2020). Inter organizational practice committee recommendations/guidance for teleneurology in response to the COVID-19 pandemic. Arch Clin Neuropsychol. 34;1314-1334.

Cullum M. Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment. J Int Neuropsychol Soc. 2014: 20; 1028-33

Brearly TW et al. Neuropsychological test administration by videoconference: a systematic review and meta-analysis. Neuropsychol Rev. 2017: 27; 174-186.

Grosch MC et al. Initial practice recommendations for teleneuropsychology. Clin Neuropsychol. 2011: 25; 1119-1133.


Articles related to general telerehabilitation

Tenforde AS, Hefner JE, Kodish-Wachs JE, Iaccarino MA, Paganoni S. Telehealth in Physical Medicine and Rehabilitation: A Narrative Review. PM & R : the journal of injury, function, and rehabilitation. 2017;9(5S):S51-S8.



No items found