Conducting a Telemedicine Neurologic Examination with Jennifer Robblee, MD

Jennifer Robblee, MD, shares best practices for a virtual headache visit

In the wake of the COVID-19 pandemic, headache practices have transitioned where possible to telemedicine. In this way, they can limit viral spread and protect patients, physicians and staff. However, not all aspects of a physical face-to-face neurologic exam readily translate to the virtual medium. To help healthcare practitioners have successful headache visits through video conferencing, AHS hosted a Facebook Live with Jennifer Robblee, MD. During the stream, she discussed how to conduct a telemedicine neurologic examination.

In the video, Dr. Robblee explains telemedicine techniques, gives advice on preparing patients for the appointment and explains how to modify common neurological exam techniques to fit the necessary limitations of telemedicine.

Preparing Patients for Their Telemedicine Visit

Dr. Robblee says that doctors should prepare their patients for the examination in advance. This includes listing any items that must be gathered before the appointment begins, such as a flashlight, ice cubes and a thermometer. Dr. Robblee highly recommends that a family member be present during the appointment to assist with some of the exam maneuvers. This is especially helpful if the patient has issues with mobility, dizziness or balance.

To follow best practices, she explains that practitioners should remove any distractions in the video background that might exacerbate symptoms in a patient with a headache disorder, like sun glare. Additionally, physicians should maintain eye contact by looking directly at the camera. If you need to check a patient’s health record, tell them why you are looking away so they know you are still attentive.

The Telemedicine Neurologic Exam

During the Facebook Live, Dr. Robblee walked viewers through a physical exam, including collecting vital signs like temperature, blood pressure and BMI. She also demonstrated assessing mental status and cranial nerves, and performing motor, sensory and coordination exams. “The good news is that a majority of our physical exam is a really reliable tool that we can do through telemedicine,” she said.

For example, it’s still possible to comment on mental status. Practitioners can do this by observing speech rate, volume and articulation, and assessing the patient’s thought process. If there’s reason to be concerned about changes in cognition, practitioners can walk patients through tests like the Montreal Cognitive Assessment and the Mini-Mental State Examination if they have a pen and paper and you are able to print out the necessary images for them to see. If your telemedicine software allows for screen sharing and whiteboard use, that could be another option.

Limitations of Telemedicine

One limitation of telemedicine is that providers can’t conduct a funduscopic exam, but Dr. Robblee pointed to other ways to assess the patient’s vision. Providers can ask the patient to cover one eye at a time and ask them what they see, use a red object to assess red desaturation or print out the NIH stroke scale cards to test for visual field defects. Other tests in a cranial nerve exam can be conducted by asking the patient to get closer to the camera; assessing their pupils, tongue and jaw movements. While the ability to conduct a motor exam is limited, many maneuvers like pronator drift, squats, and satellite sign can indirectly assess strength. The sensory exam may require the patient have a helper, but can provide at least a subjective report. Coordination and gait can be assessed similarly to a face to face visit in clinic.

While there are some limitations, providers should be able to remotely conduct a neurologic exam. It’s important to remember that you can comment on a lot by walking the patient through simple tests for strength, coordination and numbness. You can also glean much from a thorough headache history.

The American Headache Society is committed to providing support for headache clinics and practitioners during the COVID-19 pandemic. For more on the latest headache information and studies, visit the AHS News page.