Physiotherapy management of Acute Concussion via Telehealth; a Case Study

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Abstract

Clients referred to concussion services in New Zealand during periods of heightened pandemic response primarily received their health care via some form telehealth. Physiotherapy might be considered a ‘hands on’ discipline, however, with no alternative during level 4 and 3 restrictions, Physiotherapists attempted to address the needs of their clients remotely. This case study discusses the achievements and limitations of delivering the physiotherapy component of a concussion service to a client sustaining a non-sports related concussion.

Introduction

In mid-March 2020 the New Zealand Government put the country into 7 weeks of significant restrictions as part of the nation-wide Covid-19 pandemic response. 1 These restrictions extended into the delivery of health care, with very little ‘hands-on’ therapy available. This response was repeated again in 2021, with Auckland working and living under level 4 and then 3 restrictions for over 100 days. The health care system had to adapt to these restrictions and utilisation of telehealth became commonplace. Telehealth has successfully been utilised for the management of musculoskeletal injuries 2 and neurological conditions 3 however little or no evidence is available related to the use of telehealth in non-sport related concussion management.

Case Presentation

The client, a 42 year old woman sustained a concussion when hit in the right side of the head by a car door falling closed. She reported no loss of consciousness but she described immediate pain “like an explosion” at the site of impact. Over the next two days she experienced worsening symptoms of dizziness, nausea, fatigue, headache, cognitive changes, stuttering, light and sound sensitivity and the sensation of being off balance. She then presented to the local emergency care centre where they diagnosed her with concussion and requested ACC refer her to a concussion service for ongoing management.

Due to the Covid-19 restrictions in place at the time, home visits were not possible and the entire concussion service was delivered remotely via Zoom. Her symptom reporting at the time of her initial contact with the concussion service is provided in Table 1.

Table 1: Symptom reporting at initial review by the concussion service, 2 weeks post injury

During the initial physiotherapy assessment the client identified dizziness and nausea as her most concerning symptoms.  Dizziness was described as “whirling” and provoked by postural changes. Nausea worsened when travelling in a car or being in a supermarket. She had returned to walking her dog daily, but was only managing 10 minutes compared to her usual 30 minutes and was walking more slowly. She was unable to drive her car due to the severity of the symptoms.

Assessment via telehealth was limited but appeared to demonstrate:

• Full neck range of movement but with subjective reporting of pain, stiffness and clicking on right rotation.
• Broken pursuit with eye tracking toward her right and was unable to detect some visual information in her right peripheral visual field.  Saccadic and vergence movements appeared normal.
• Limited VOR testing by horizontal head shaking with gaze fixation on a target in line with the computer screen provoked immediate dizziness and nausea, almost to the point of vomiting. This subsided to baseline after 10 seconds of cessation of movement.
• The client was able to maintain balance on both conditions of the Rhomberg, but there was increased sway with eyes closed and subjective reporting of the ‘whirly’ sensation. The client was extremely unstable attempting heel-toe walking and the test was halted after 2 steps due to safety concerns.
• No obvious vertigo, dizziness or nystagmus during a self-administered Dix-Hallpike manoeuvre.

Analysis

The client had a medical diagnosis of concussion sustained from a car door hitting her head. She required education about concussion, symptom management and principles of recovery, which in this service this is primarily provided by the Occupational Therapist.   The somewhat limited assessments able to be done by Physiotherapy suggested she had some oculomotor dysfunction and difficulty processing moving and peripheral visual information. Benign paroxysmal peripheral vertigo (BPPV) was unlikely, although unable to be excluded completely. The Physiotherapist also suspected that some symptoms were cervicogenic in nature but it was not able to be confirmed or excluded at this time.

Physiotherapy Management

• Miss Z was initially taught a smooth pursuit activity, visually following a target through range for 30 seconds x3, 3x/day, stopping if dizzy. This was progressed in 30 second increments until she was able to do 2 minutes maintaining smooth pursuit.
• VOR Desensitisation to visual movement using the Movement Sensitivity Test as an exercise. Initially this was done sitting in a study chair for safety and facing a plain background to reduce visual stimulation and help minimise symptom provocation, up to 2 minutes, 3x/day. This was progressed by gradually increasing the ‘busyness’ of the background, as she tolerated it.
• A range of balance activities were provided aimed at improving sensory integration and safety in standing. These included tandem stand, SLS and tandem walking.
• Education and discussion regarding the role of cardiovascular exercise in concussion management and minimising symptom provocation. She was encouraged to try and walk, maintaining social distancing, for at least 15 minutes per day for the first week and increase this by 5 minutes per week to 30 minutes if this did not provoke her symptoms.
• Due to the constraints of the concussion services contract she was referred to another provider for management of her neck.
• Over the course of a month the client demonstrated improvements in her subjective and objective assessments. Smooth pursuit was normal and whilst she still reported dizziness it no longer limited her participation in daily activities. She could now walk heel/toe across the room, although had not returned to her baseline. She still complained of some nausea with movement in her peripheral vision. However she was not yet confident to drive. Sessions were held weekly via Zoom but were kept to a maximum of 30 minutes due to fatigue and decreased concentration and ability to watch the computer screen.
• Her therapy is ongoing.

Discussion

It has been the experience of this physiotherapist, like others,7 that telehealth can be an effective modality for assessment and treatment of concussion when no other alternative is available. The therapist must be able to adapt assessments, depending on safety and the limitations of technology, without compromising the quality of the results. Additional support was also required to optimise assessment and treatment techniques.

For example, extra time for education was provided prior to doing BPPV testing and treatment, including watching an educational video demonstrating the technique. The evidence does support the effectiveness of home treatment of BPPV 9, 10, 11.

The initial balance assessment must be undertaken with more caution, ensuring that the client is in as safe a position as possible to reduce their fall risk12. There may be some clients for whom the fall risk is too great to assess via zoom. As it is not possible to provide a written session summary with the client in person, it appears to be more effective if all instructions for exercises are emailed out to them after each session, to improve compliance. This is especially true for a balance program.

Other barriers with telehealth include patient technical literacy, their ability to access appropriate technology13, cost, and lack of desire to use the modality. This was often overcome by providing technical support on operation of the telehealth technology over the telephone.

One of the most important aspects of telehealth is client compliance and satisfaction. Telehealth is becoming an accepted method of delivery of service14, especially during the

Covid-19 lockdown15. It is harder to establish rapport, but this can be done with patience and effective client communication. Overall client satisfaction levels are acceptable16.

It was felt by this therapist that this client was receiving an adequate level of care, the client indicated she was happy with her care, and she was making consistent improvements. It would have been easier if she had been able to tolerate looking at the computer screen for longer so that sessions were not quite so rushed. She found it uncomfortable to look  directly at the screen for pursuits/saccades to be assessed; and having family members look for nystagmus for BPPV was not ideal, but was the best possible option at the time. Visual motion sensitivity exercise was chosen to minimise neck discomfort from movement. If she had had access to musculoskeletal physiotherapy to have her neck treated it would have been beneficial.

The table below describes the effectiveness of various assessment and treatment techniques delivered by telehealth to Miss Z.

Conclusion

For this client the delivery of the physiotherapy component of a concussion service via telehealth appears to have been successful. Whilst there were some assessments that needed to be modified and some that were not able to be completed at all, the client reported improvements in all the relevant areas and reported high satisfaction in the service delivered.

Some research has been done on concussion and telehealth with regards the sports athlete7,17,18 and USA veterans,13, 19, and it is becoming recognized that telehealth does have an impact on the therapist clinical decision making process20. More research is needed specifically in the field of concussion care via telehealth for the general population, to gain a better understanding of benefits and limitations.