Sideline analysis: Telemedicine and football

Despite increased awareness of concussion, athletes with the condition may go unrecognized and return to play prematurely, risking subsequent and more serious injury. Telemedicine links athletes on the field to neurologists at remote locations, offering expert concussion evaluation in real time. Mayo Clinic in Phoenix/Scottsdale, Arizona, a pioneer in teleneurology, is testing the feasibility of teleconcussion assessments at collegiate football games.

"The final results are still pending. But preliminarily, it looks as though our telemedicine evaluations are consistently in agreement with the assessments of team doctors on the sidelines," says Bert B. Vargas, M.D., a consultant in the Department of Neurology at Mayo Clinic's campus in Arizona.

In addition to the collegiate study, Mayo Clinic is conducting remote concussion assessments of high school and youth football players. "About 60 percent of high schools do not have access to the care they need to identify concussion on the sideline," Dr. Vargas says. "Teleconcussion is one way to bridge this gap."

Expertise for vulnerable brains

Mayo Clinic's extensive telemedicine network began by linking rural hospitals in Arizona with stroke specialists at the Phoenix/Scottsdale campus. Like stroke, concussion is an acute condition requiring rapid assessment with a standardized protocol. Mayo Clinic's protocol for remote concussion evaluation incorporates the King-Devick Test along with elements of the Sports Concussion Assessment Tool, including the Standardized Assessment of Concussion and the Balance Error Scoring System. Assessments are performed at baseline and also at the time of suspected injury.

"We can easily do these tests rapidly through the telemedicine equipment," says Amaal J. Starling, M.D., a consultant in the Department of Neurology at Mayo Clinic's campus in Arizona. She notes that the King-Devick Test, which measures the speed and accuracy of rapid eye movements and attention, "is very sensitive for detecting concussion since the networks that control eye movements are distributed widely throughout the brain."

Although concussion in professional sports has garnered much attention, the dangers are even greater for young athletes. "The developing brain appears to be more vulnerable to the shear and strain forces placed on the brain during a concussion," says David W. Dodick, M.D., a consultant in the Department of Neurology at Mayo Clinic's campus in Arizona. "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."

High school or younger athletes also tend to recover more slowly than older athletes. "The reasons for that are not entirely clear," Dr. Dodick says. "But the normal recovery time for concussion that's found in the literature — seven to 10 days — is, I believe, an underestimate for youth athletes. They are more susceptible to repeat concussion and may be more likely to have symptoms and neurological impairments that persist."

Full-field perspective

Mayo Clinic's collegiate football study was done in partnership with Northern Arizona University (NAU). A Mayo Clinic mobile telemedicine robot was stationed on the sidelines during NAU home games in Flagstaff and taken to away games. Neurologists at Mayo Clinic's campus in Phoenix/Scottsdale controlled the robot remotely. NAU medical staff performed their normal duties, assessing injured athletes and making decisions about return to play.

However, when a player was pulled aside with suspected concussion, the Mayo neurologists conducted a parallel evaluation remotely and reached their own conclusion about whether a concussion had occurred. Subsequent analysis showed strong agreement between decisions made remotely and on the sidelines. In addition to controlling the robot, the Mayo neurologists watched live broadcasts of the games, gaining an important perspective not available to medical personnel positioned on the sidelines.

"Physicians standing in a fixed location on the sideline have a relatively limited view of what's happening on the field," Dr. Vargas says. "There have been a number of situations in collegiate and professional football where an athlete looks altered. Even the broadcasters can identify that something is wrong. But the medical staff may not have seen the problem. Although the field physicians are experts at recognizing and evaluating athletes with concussion, sometimes they are unable to see everything from the sidelines."

The Mayo neurologists hypothesized that watching a game from multiple camera angles, with the ability to rewind and slow down the broadcast, would help identify players who need assessment. Although the utility of that perspective requires further study, "the NAU medical staff was very pleased that we could alert them if someone needed to be pulled and evaluated," Dr. Vargas says.

Testing high school and youth athletes

In fall 2014, Mayo Clinic is providing teleconcussion coverage for high schools in Phoenix and surrounding cities. "We can be at home on call and available for these schools in case of an injury," Dr. Starling says. In schools where a telemedicine robot isn't feasible, a tablet computer can be used.

In addition to acute evaluation, the teleconcussion network is used for follow-up evaluation in rural clinics. "We can make recommendations about returning to school, about appropriate accommodations for learning and about return to play," Dr. Starling says. "It's a huge advantage for rural areas without a comprehensive concussion center nearby to have this service."

Mayo Clinic is also partnering with Arizona Pop Warner, a youth sports organization, to conduct baseline neurologic testing and future research on more than 2,500 youth football players and cheer athletes. The inspiration for Mayo's initiative came from a White House summit on concussion, where President Barack Obama urged physicians to advance research on protecting young athletes.

"We believe Mayo Clinic can set an example for the rest of the nation," Dr. Dodick says. "We need to do everything we can, starting at the Pop Warner level, to protect these players."