Telemedicine is a subset of telehealth. It refers to practicing patient care via a digital platform instead of the provider and patient being physically together. Generally, this is a video visit via a device that connects to the internet such as a computer, tablet, or smartphone.

There are a number of benefits to using telemedicine: 

1. Telemedicine eliminates the spread of infectious diseases from both patient to patient and patient to healthcare provider & staff.
2. Telemedicine saves time by being able to schedule in more convenient blocks.
3. It reduces overhead costs.
4. It increases patient access to care by removing barriers such as transportation, being too impaired to come into the office, or being in a rural area.

While there are certainly benefits of telemedicine, there are some possible cons that should be considered:

1. Not all patients have access to the technology needed to conduct a telemedicine visit.
2. You don’t have as much control over their environment. 
3. There’s a possibility of cybersecurity issues. 
4. Some patients may be confused or overwhelmed by the technology.

Now that we’ve weighed the pros and cons, you can decide for yourself whether telemedicine is appropriate for your practice. 

Learn more in this webinar replay: Leveraging Telemedicine for Concussion Care.

Continuing our physical therapy in concussion management series we’re moving on to the three areas of treatment. Today, we’re covering vision therapy for concussions.

Did you know 1/3 of patients dealing with concussions experience visual problems? This can include double or blurred vision, dizziness, and issues following a moving target. Axonal injury or blunt trauma to the visual control systems cause these symptoms. Physical therapists can detect visual problems by conducting the Vestibular-Ocular Motor Screening (VOMS). Once they know the issue they can use any of these 10 vision therapy techniques for concussions:

1. Pencil Push-Ups
2. Pointer and Straw
3. Brock String
4. 3 Dot Card
5. Life Saver Card
6. HART Chart
7. Marsden Ball
8. Rotator Pegboard
9. Michigan Tracking
10. Thumb Pursuits and Saccades

Tune in next week to learn how physical therapists help with vestibular rehab.

Following up from last week, it’s time to jump into some of the biggest concussion myths. Myth #1 sports injuries are the leading cause of concussions.

Sports concussions, especially concussions in youth sports, are a hot topic in the media. However, it’s important to keep in mind that a head injury can occur outside of athletics too. According to the Centers for Disease Control and Prevention (CDC), falls are the number one cause of concussions followed by car accidents. This puts anyone at risk for a head injury, not just athletes who play contact sports.

You can protect yourself by learning the signs and symptoms of a concussion. This will help you know when to seek medical help if you suffer a blow to the head.

Concussion care providers can recommend activity for patients to do at home to maximize healing opportunities. Here are some examples:

• Light cardio as tolerated — walking outdoors to train the eyes to find movement and get the eyes moving side to side.
• Meditation — this helps patients dealing with anxiety or stress about the future by focusing on the present and calming the nervous system.
• Gentle yoga — eases patients into trusting their bodies and feeling safe with simple movements.
• Specific eye or vestibular exercises — these can be done alone or incorporated with light cardio while looking around, yoga while shifting the gaze up and down, or meditation by focusing on one point.

Another key factor to emphasize is keeping a routine. This is crucial for targeting concussion-specific symptoms and will help patients maintain a consistent sleep cycle so they can bounce back to everyday activities.

For more information about starting a concussion care practice download our Concussion Care 101 Guide on concussioncareproviders.com.

Return to play is a stepwise process based on a patient’s heart rate and presence of their symptoms. All cognitive and physical activities should be supervised by a trained concussion care provider to make adjustments when needed.

To begin this phase of rehab, patients should meet the following return to play criteria:

• They are symptom-free at rest, with cognitive exertion, and physical exertion. Activities such as reading, checking emails, going for a walk, or attending a yoga class do not aggravate symptoms
• They score within normal limits on BESS and VOMS
• They are back to (or better than) baseline results on neurocognitive tests

Keep in mind patients suffering from post-concussion syndrome will still have symptoms that worsen with cognitive and physical exertion. You will have to bend the guidelines and encourage them to move through their symptoms to interrupt the chronic pain cycle. A trained concussion rehabilitation specialist can help determine this balance of activity.

When patients are ready to return to physical activity, healthcare providers and concussion rehabilitation specialists will continue to play an active role. For athletes and non-athletes alike, monitor their heart rate and symptoms to make adjustments. The more information patients share, the better their rehab plans will be going forward and the better care they will receive.

These concussion rehabilitation steps are a gradual process to return to physical activity. Always be sure to have a trained concussion care provider on hand for supervision:

1. Rest — Assign the patient 24 to 48 hours of rest that includes removing extended screen time, homework, or cognitively demanding tasks.
2. Symptom-limited activity — Integrate activity, about ten minutes whether cognitive or physical and monitor symptoms the entire time.
3. Light aerobic exercise — Add activity that gets the heart rate up without aggravating symptoms. A walk outside or on a treadmill, swimming, or stationary cycling for 20 minutes at 70% HRMax.
4. Sport-specific exercise — Incorporate movement for 30 minutes at 80% HRMax. If your patient is a hockey player, suggest going out to skate and doing non-contact drills. If your patient is a football player, test sprints, get on the ladder, or try sport-specific moves. Once your patient has integrated back into practice, they should still sit out contact drills and monitor their symptoms.
5. Non-contact training drills — Add activity that requires coordination and cognitive skills. Progress to more complex training drills for 60 minutes at 90% HRMax.
6. Medical clearance — Have a trained healthcare provider conduct a medical exam before moving on to normal training and returning to sport or activity.
7. Full contact practice — In a controlled environment incorporate contact while monitoring symptoms. Focus on restoring the patient’s confidence and function while performing normal training.
8. Return to sport — Patients may resume full activity and get back into games. The amount of time it takes to reach this concussion rehabilitation step will vary by athlete and depends on the symptoms they’re reporting.

This gradual process of returning to exercise or sports works best with open communication about symptoms. If a patient reports their symptoms being a 5 or 6 out of 10, the activity is too aggravating. By listening and working within their limits you can create a rehab plan specific to each patient.

The standards for concussion rehabilitation and treatment have changed over the years. Previously, cocoon therapy, where patients were isolated in a dark room for extended periods of time, was the most recommended form of recovery. Now, there is research and new concussion treatment guidelines provided by the CDC, that emphasize the importance of a gradual return to life as soon as possible.

Gradual return to activity is best done with the healthcare provider serving as a guide throughout this journey. You will help your patients manage their symptoms while motivating them to know what they can work through and when they should ease off. The main objective is to avoid isolation so patients have an easier time getting back to life and their routines.

Returning to cognitive activity

Releasing a patient to cognitive activity isn’t something thought of right away. For athletic trainers, the focus has typically been on getting athletes back into sport. But all patients, no matter if they are student-athletes or work in an office, need to have a certain cognitive ability to learn, check emails, make calls, and get through the day.

Patients with a concussion can’t participate at full capacity since every cognitive ability they have — attention, memory, focus — are affected. While this is true, maintaining a regular schedule throughout rehab is important. As soon as a patient is ready, plan to integrate them back into their routine even if that means half days to start.

Returning to learn

Many schools do not have the resources to establish a return to learn or activity protocol. In these instances, the healthcare provider will be the point person to help patients navigate their lives as they return to normal.

Start by recommending changes patients can make to their surroundings to support their symptoms. Here are a few examples:

• Using earplugs to soften noise
• Wearing a hat or sunglasses to shade light from their eyes
• Communicating with their teacher or employer if they are feeling tired, overwhelmed, or need to take more breaks
• Closing their eyes to focus on auditory skills and limit visual distractions
• Asking for more time for tests

All of these adjustments may seem minimal but they can have a huge impact in supporting children with concussions, as well as adolescents, or adults returning to work. The goal is to encourage patients to get back to their routines instead of staying at home until they are 100% symptom-free. Stay tuned for flash briefings about returning patients to physical activity and return to play protocol.

Using the data gathered in the clinical interview, you can create an individual concussion treatment and recovery plan. Refer your patients to the appropriate specialists by determining their clinical trajectory.

Here are the six clinical trajectories your patient will fall within:

1. Vestibular — you’ll notice balance, or pro-pree-uh-ception difficulties
2. Ocular — this manifests in visual changes or visual differences
3. Cognitive fatigue — patients may report chronic tiredness, mental disturbances, memory changes
4. Post-traumatic migraine — patients more prone to migraines may report constant headaches that can sometimes last months. Sounds and light will be debilitating, and they may even become dizzy
5. Cervical — this will show through neck pain, neck dysfunction, or an overall loss of range in motion
6. Anxiety/mood — you may observe persistent low mood type symptoms, or your patient can display constant anxiety with no necessary reason behind the worry

Communicating the treatment plan to patients

Once you figure out the clinical trajectory, it’s important to walk through a patient’s rehabilitation plan and answer any questions. By explaining your treatment ideas you build trust and show compassion. This also creates a team atmosphere and teaches patients why you are recommending a specific type of treatment.

During the clinical interview, you will do more talking than you think necessary. The goal is to gather as much information as possible by getting the patient to report their symptoms. You will also administer a neurocognitive test, perform the Vestibular-Ocular Motor Screening (known as VOMS), and the Balance Error Scoring System test (known as BESS).

Neurocognitive testing to measure brain function

Ideally, you want a patient to complete a neurocognitive test, such as ImPACT baseline, before an injury. If a test has not been taken, you can compare their post-injury results to normative data. During the ImPACT post-injury test, you will review a list of signs and symptoms to understand how the patient feels. You can use this data throughout your patient’s recovery to show them how far they have come.

VOMS test to detect visual and vestibular issues

Next, you will conduct a screening that tracks eye movements and allows you to observe how the vestibular system is working. When conducting VOMS you will get to see any change in symptoms as exercises are completed. There are a series of eye movements such as side-to-side without moving the head, up and down, shaking the head and keeping the eyes steady on one point. These will help you understand the patient’s deficits and where you can cater rehab going forward.

To see a VOMS test demo, go to ImPACTQuickTest.com/VOMS.

BESS balance testing

The BESS balance test evaluates a patient’s body awareness, postural stability, and control of their body after a head injury. It’s common for athletes to have BESS baseline results prior to injury which gives you data to compare. The general public likely won’t have access to this information but you can still use these results to track their progress as the number of errors they have decreases.

To see a BESS test demo go to ImPACTQuickTest.com/BESS.

Having objective tools to measure recovery is beneficial for a couple of reasons. They can help document your patient’s rehabilitation and show progress over time. Some tools are even covered by CPT codes for concussion care which can generate extra revenue.

No matter how your patient hits their head, the body is undergoing a traumatic experience. This sets the nervous system into fight or flight mode, making the body work harder than usual. Current recommendations advise complete cognitive and physical rest for 24 to 48 hours. This allows the body to settle and begin the healing process.

Along with this information, educate your patients about removal from activity, the importance of reporting symptoms, and alarming signs to look out for.

Removal from activity

Immediately after a head injury, patients must stop performing activity to avoid a second impact. They should also seek medical care as soon as possible to get a full concussion evaluation. As mentioned, this is followed by 24 to 48 hours of physical and cognitive rest including not watching TV and staying off their phones and laptops.

Importance of reporting a concussion

A patient’s ability to fully recover requires having a strong support system. This includes a medical team, their family members, friends, coaches, and teachers or employers. Encourage your patients to report their concussion to any of these people. This ensures they have help available in all areas of their lives. With everyone on the same page, it will be less likely to miss key symptoms and the patient will get back to normal that much sooner.

Danger signs to report right away

Preparing your patient for the variety of symptoms they can experience will help them know what to report. If any of the below worsen with time or do not seem to improve, pursue additional care:

• Headaches
• Weakness
• Vomiting
• Dizziness
• Deafness in the ears
• Blindness in the eyes
• Slurred speech
• Convulsions
• Change in consciousness
• Irregularities with the pupils such as not being equal, not dilating to light, or staying wide open

These worsening symptoms are all red flags that you, your patient, and their support network should monitor throughout the recovery process. If your patient reports more severe symptoms, emergency care is recommended.

There are three significant factors to include in your concussion evaluation — objective tools to measure recovery, a concussion diagnosis plan, and recovery education for patients.

Baseline testing

In an ideal world, all patients would have baseline testing done before an injury. Because it records brain function in a healthy state, the baseline results can be used to assess progress. After a patient sustains a head injury, the same memory, visual, and spatial testing can be done to compare data side by side. This objective information can assist you when making treatment plans that are specific to your patient’s symptoms and needs.

Diagnosing a concussion

When it comes to diagnosing a concussion, there is no FDA cleared test that provides a diagnosis. It is up to you, the healthcare provider, to use different tools and medical equipment for concussion diagnosis and treatment. This can include:

• Neurocognitive testing
• Physical examination
• Balance screening
• Vestibular ocular examination
• Reviewing a concussion symptoms checklist
• Asking questions about the head injury and the current cognitive state

With concussion treatment and rehabilitation evolving over the years, make sure your patients understand their recovery process. You can properly set expectations by educating them about some of the most common myths like avoiding sleep after a head injury, extended periods of rest in a dark room, and long concussion recovery times.

For more information about these myths go to baselinetesting.com and download our concussion myths infographic.

Designing a space that accommodates concussed patients is important if you plan to specialize in concussion or brain injury. A few things to think about include the office lighting, where you will gather patient information, and how you will conduct evaluations. All of these considerations help your patients feel comfortable at a time when they’re not feeling their best.

Here are some tips to create the ideal clinical environment:

1. Lights — Avoid a bright fluorescent atmosphere by dimming or softening the lights. This prevents triggering visual symptoms some of your patients may have.
2. Privacy — Create a quiet space with minimal distractions that allows your patient to feel safe speaking to you one-on-one versus out in the open.
3. Breaks — If you see your patient getting tired, frustrated, or unable to focus, stop and take a break. It may be best to split your evaluation into two parts to allow time for rest post-concussion.
   Prepare patients for how they may feel — After the evaluation your patient’s symptoms may worsen. Let them know this is normal and to take time to regroup instead of scheduling back to back appointments.

Multidisciplinary Team Members

Along with creating a suitable environment, you’ll need a multidisciplinary team with specially trained healthcare professionals. A few members to have on your medical team include athletic trainers, sports medicine physicians, neuropsychologists, psychologists, optometrists, as well as physical and occupational therapists.

To find concussion specialists in your area head to ConcussionCareProviders.com.

When talking to patients about concussion, it’s important they understand the basics. This includes educating them about their injury, the causes, and symptoms to look out for.

Start by explaining a concussion is the most common traumatic brain injury caused by a force, blow, or trauma to the head. It can cause short-term changes to the mental status that affects coordination, balance, and even changes in personality right away. Since this is a newer research field, the definition changes as more information becomes available.

Common causes of head injuries

If a patient asks about the most common causes, they may be surprised to find out contact sports like football and hockey are not the only way concussions can be sustained. In fact, according to the CDC, falls are the number one cause with car accidents coming in second. This puts anyone, not just athletes, at risk for concussion.

Concussion prevention

When it comes to prevention, there is no specific method or equipment that will entirely protect an individual from getting a concussion. While helmets are vital in keeping the skull safe from fractures and more serious injuries, concussion education is the best prevention you can offer. Teaching patients the concussion risks and signs as well as the importance of baseline testing is valuable information you can share.

Concussion symptoms

Because every concussion is different, spend a good amount of time informing your patients about the symptoms. This will help you in making treatment decisions when patients have to report how they are feeling. Here are signs you may recognize in a patient who has sustained a head injury:

• Problems with concentration/memory
• Sensitivity to light and noise
• Dizziness or lightheadedness
• Double or foggy vision
• Headaches
• Nausea

These concussion symptoms might not manifest right away and can appear weeks or even months later. This makes it necessary for you to know and monitor your patients. Changes in behavior are more difficult to measure but something to be aware of as well.

Post-concussion syndrome

While most concussions heal within three to four weeks, 20% of patients experience lingering symptoms sometimes years after the initial injury. If your patient continues to report sensitivity to light, increased tiredness, or headaches, continue exploring the issue while helping them manage their symptoms.

For more information to share with your patients download our Concussion 101 Guide at baselinetesting.com.

Concussion care and recovery require a multi-faceted approach. When you’re considering the tools you want to include in your comprehensive clinical evaluation, it’s important to keep in mind scientific basis (or the research surrounding the tool), FDA and regulatory clearances, and ease of use. Here are some of the tools you need to help your concussion medical practice succeed:

• Removal from Activity Screening Tools: Healthcare providers should use objective tools as well as a comprehensive exam to screen for concussions. ImPACT Quick Test is a screening tool that helps with removal from activity decisions and can be administered on an iPad immediately following a suspected injury at the competition site, workplace, or point of care.

• Computerized Neurocognitive Testing: Neurocognitive testing offers an objective measure to track neurocognitive functioning. ImPACT and ImPACT Pediatric are cognitive tests that help healthcare providers assess concussions and make important care decisions.

• Vestibular/Ocular Screening: Approximately 50% of post-concussion patients report vestibular symptoms. Vestibular Ocular Motor Screening Exam (VOMS) is a free, simple assessment that may help dictate treatment plans. The VOMS is included with ImPACT Quick Test.

• Balance Screening: Balance can be an important measure of post-concussion status, especially shortly after an injury. The Balance Error Scoring System (BESS) is a straightforward test that requires only a stopwatch, a balance pad, and an assistant to act as a spotter. The BESS is included with ImPACT Quick Test.

The tools mentioned above are in addition to a medical exam and a symptom check. And of course, post-injury assessments should always be administered by a trained healthcare provider. Check out our Concussion Care 101 Guide for more information on setting up your concussion care medical practice.

I’ve seen a LOT of people talking about getting a concussion and just sitting out of school or work for a few days and trying to get back to regular activity without ever going to the doctor. Concussion care has advanced drastically in the past few years, and one of the most important things to keep in mind is that there are specially trained concussion care providers who can actually help you get better. If you don’t get help, your brain health could be at risk. Let’s talk about some of the benefits of seeing a healthcare provider who is specially trained in concussion care.

First and foremost, it’s important to see ANY healthcare provider after a head injury, whether it’s an urgent care, your primary care physician, or an emergency department for severe injuries. They’re the first line of defense to diagnose a concussion. Getting an actual concussion diagnosis is way more important than you think. Without one, you may be just told to rest until you feel better, which we know is not best practices for healing from a concussion.

Concussion specialists are just that – they’ve received special training in the management of concussions. General practitioners have received some training in concussion care, but they may not be entirely up to speed on recent advances in concussion care. Concussion specialists are an important resource for helping patients recover from a concussion without having to spend weeks or months resting.
They know that every concussion is different and that every concussion patient needs to be treated based on their individual needs. They’ll perform a wide array of assessments to make sure they have a full picture of YOUR individual injury and can recommend treatment and rehabilitation specific to your needs.

Concussion specialists work in teams to help concussed patients get better. There are doctors, neuropsychologists, physical and occupational therapists, and other people equipped with the skills to help you fully recover after a concussion. It’s very important to seek help if you ever get a concussion – you won’t regret getting the help you need. Head to ConcussionCareProviders.com to find a concussion specialist in your area so you know who to call if you ever get a concussion.

Let’s talk a little about what a return to play protocol and a return to activity process after a concussion looks like. I’ve heard a lot of concerns that an individual will never be the same after having a concussion, or that they won’t get to do the activities they enjoy. The good news is that if you see a trained concussion care provider, you can rest assured that you will feel better.

This information on returning to activity after a concussion comes from research and expert consensus. When you first receive a concussion, you’ll be told to rest for a day or two. The doctors will determine what “kind” of concussion you have, based on a comprehensive evaluation.

Based on your symptoms and areas that need improvement after concussion, you’ll be prescribed specific treatment and rehabilitation. Then, you’ll go through a progressive return to activity. You’ll start with light activity that doesn’t make your symptoms worse. You’ll progress to light exercise, then exercise specific to the activity you want to get back to. This means sport-specific activities for athletes, or everyday exercise for non-athletes.

You’ll increase activity in each step. If your symptoms get worse, you’ll move back down to the previous step and try again. A lot of people are surprised that doing activity makes your symptoms better, but that’s what the research has shown. Keep in mind that this is all supervised by a trained healthcare provider. You shouldn’t be trying to tackle returning to activity on your own. Finally, once you can do full exercise without symptoms, your doctor will clear you to return to full activity.

The important thing to keep in mind here is that you NEED to see a trained healthcare provider to do a return to play protocol safely. Visit ConcussionCareProviders.com to find a trained healthcare provider in your area.