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The optimal approach to a clinical physical examination via telemedicine is still being explored. The medical community has no standardized or widely followed criteria for telemedicine examinations, so a broad spectrum of approaches is used. Unfortunately, the need for telemedicine is outpacing physical examination validation research. Given that certain specialties have been using telemedicine longer than others, lessons from those specialties might aid in developing standardized protocols for telemedicine. Neurology has been at the forefront of telemedicine use, initially through stroke care and later in multiple subspecialties. We present a framework for optimizing the history taking and physical examination process via telemedicine based on our experience in neurology. This mainly includes remotely examining a patient unassisted or with an untrained assistant present on the patient side of the connection. We also discuss the need for trained, certified assistants to assist the off-site physician in history taking and physical examination. These certified assistants would be allied health professionals who perform high-quality cued patient examinations under direct physician supervision with no responsibility to diagnose or treat. This contrasts with the approach seen in advanced practice providers such as physician assistants and nurse practitioners who undergo years of training to diagnose and treat patients under supervision. This training process would serve as a stepping stone for the development of dedicated certification programs for neurology and other medical specialties; however, assessments of practical training, costs, implementation, and longitudinal quality are warranted.
The criterion standard for physical examination is in-person examinations; however, the quality of in-person examinations varies considerably based on the examiner’s education and experience, even for physicians and advanced practice providers (APPs) of different specialties. Widespread telemedicine implementation has facilitated access to medical care worldwide but not without particular challenges. For example, history taking is easily translatable to a virtual setting, but physical examination can be problematic. This is especially true in specialties with extensive physical examinations using telehealth models for some time, such as neurology [
Currently, a wide assortment of telehealth equipment exists to aid the remote health care provider. Generalized digital cameras can function variably as otoscopes, ophthalmoscopes, and dermatoscopes, and can be used to perform specialized examinations. Some telemedicine units are equipped with electronic stethoscopes to transmit data to be interpreted by the remote examiner [
Certification programs geared explicitly toward physical examination skills are varied and still in the early adoption phase. For example, Thomas Jefferson University offers an online 5-week program to become a certified “Telehealth Facilitator” that imparts the skills necessary to manage the interface between the provider and patient, and to address any arising technological problems during the encounter [
Given that neurology relies heavily on detailed history taking and precise physical examination to localize lesions, its success in the telemedicine environment can serve as a framework for telehealth implementation in other fields. Initial applications of teleneurology included acute stroke care with validation of the National Institute of Health Stroke Scale performed remotely. General neurological examination via teleneurology research is ongoing to assess the reproducibility and reliability of remote neurological examination compared to in-person examinations. The adoption of telemedicine technology is outpacing the literature regarding accuracy and reliability, and although data are emerging, pragmatic models for implementation and use are needed now. The legal implications of relying on remote assistants are unclear. Causes of telemedicine litigation can typically be related to issues with informed consent, breaking state or federal laws, data breaches, diagnostic errors, and lack of policies and protocols. Trained assistants can facilitate informed consent and help provide a higher quality examination leading to fewer diagnostic errors. This would be expected to diminish litigation and improve outcomes.
The optimal way to perform a neurological physical examination and take a patient’s history remotely has been a challenge since 1999 when it was first reported possible [
The skill in performing and interpreting the neurological exam and the comfort level under various circumstances are arguably more important than whether the exam is in-person or remote. Additionally, the reliability of neurological exams will vary even among the best health care providers. Kappa statistics can measure test interrater reliability with higher scores indicating higher levels of agreement (ie, 0.01-0.20: slight agreement; 0.21-0.40: fair agreement; 0.41-0.60: moderate agreement; 0.61-0.80: substantial agreement; and 0.81-0.99: almost perfect agreement). For neurological examinations, kappa scores are better among observable signs than elicitable neurologic signs. In other words, parts of the examination with high reliability required the examiner to do less elicitation and observe [
The teleneurology paradigm involves many elements, and this paper provides a logistical framework for the patient history and physical examination elements of the encounter. Importantly, these aspects can vary substantially based upon individual patient characteristics, the availability of remote assistance, and the assistant’s training.
The acquisition of patient history should not be altered substantially due to the lack of in-person interaction. If a patient is cognitively intact, they may provide their history. If not, history may be obtained via a surrogate (eg, a family member or nursing staff), as would be the case during an in-person encounter. There is an opportunity to improve the history-taking process. During telemedicine visit preparation, the health care team can schedule coordinated group calls or video chats between the patient, family, and provider to optimize history taking. Geographically dispersed family members and caretakers can contribute to complex histories. This would add substantially to the patient history, as patients are often limited historians, and physicians must comb through the electronic medical records to piece together a story that is often documented asynchronously or even incorrectly [
Although the history gathering portion of the patient encounter is relatively straightforward, a teleneurology examination presents challenges. Nevertheless, all encounters (both assisted or unassisted) can still include the standard seven parts of a neurologic examination (ie, assessment of mental status, cranial nerves, motor system, sensory system, reflexes, cerebellar, and gait). Each subsection of the exam can be modified as needed based on the degree of assistance available (
Specially trained and certified examiners have an important role in helping to conduct specialty examinations in the telehealth setting. Although the certification process could potentially be streamlined for those who are already capable of performing adequately directed physical examinations (eg, physician assistants or nurse practitioners), full-scale physical examination–specific training and certification would be advantageous for other hospital and office staff and trainees, including nurses, hospital technicians (eg, those in neurophysiology and respiratory staff), medical trainees (eg, medical students and advanced practitioner students), and patient care assistants. This is important as the certified examiners would likely have other primary clinical responsibilities. Roles and titles must clearly be defined, as a lack of consistency in nomenclature across medical settings has led to false assumptions of tele-assistant capabilities when working with other health care staff [
Neurological examination capabilities based on assistant availability and expertise.
Exam maneuver | TAa | UTAb | UAc | Comments | |
Mental status | ✓ | ✓ | ✓ | May be limited at times based on degree of cognitive impairment, regardless of etiology (eg, dementia, delirium, or static encephalopathy). Certain elements such as cortical sensory testing/diagnosis would require a trained assistant. | |
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Olfactory | ✓ | ✓ | X | Given assistant has access to scent. |
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Visual acuity | ✓ | ✓ | ✓ | Visual acuity mobile apps are readily available. |
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Extraocular movements | ✓ | ✓ | ✓ | Saccades, smooth pursuit, convergence can be assessed by all three levels. Oculocephalic maneuvers would need TA. |
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Pupillary response | ✓ | ✓ | ✓ | Direct pupillary reflex can be assessed with eye opening/closing. Indirect needs TA. |
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Facial sensation | ✓ | ✓ | X | Gross sensation only with TA and UTA. Multimodal sensation only with TA. |
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Taste | ✓ | X | X | N/Ad |
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Audition | ✓ | ✓ | X | Weber/Rinne testing needs TA. |
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Vestibular | ✓ | X | X | N/A |
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Articulation | ✓ | ✓ | ✓ | N/A |
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Swallowing | ✓ | ✓ | ✓ | Via observing drinking and eating |
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Trapezius and SCMe | ✓ | ✓ | ✓ | Cannot assess strength unassisted but can assess symmetry |
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Tongue | ✓ | ✓ | ✓ | Strength only with TA |
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Observation | ✓ | ✓ | ✓ | N/A |
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Tone/rigidity | ✓ | X | X | To observe arm tone, UTA can sway standing patient at the hip. |
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Test of subtle paresis | ✓ | ✓ | ✓ | Pronator drift, forearm rolling test, and velocity and cadence of movement |
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Muscle strength | ✓ | Limited | X | Can still note symmetry, velocity, and functional tests unassisted |
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Light touch | ✓ | ✓ | Limited | Unassisted patients can simultaneously touch both upper or lower extremities. |
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Pain/temperature | ✓ | X | X | N/A |
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Vibration/proprioception | ✓ | X | X | N/A |
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Spinal sensory levels | ✓ | ✓ | X | N/A |
Reflexes | ✓ | X | X | DTRsf, Plantar response, Hoffman’s, abdominal reflexes, primitive reflexes, clonus | |
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Appendicular | ✓ | ✓ | ✓ | Includes heel to shin, finger to nose, rapidly alternating movement |
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Truncal | ✓ | X | X | N/A |
Gait | ✓ | X | X | Per physician discretion, standing and ambulation may be assessed unassisted or with untrained assistant, depending on perceived fall risk. TA may assess heel walking, toe walking, tandem gait, and Romberg safely. |
aTA: tele-exam with trained assistant.
bUTA: tele-exam with untrained assistant.
cUA: tele-exam unassisted.
dN/A: not applicable.
eSCM: sternocleidomastoid.
fDTR: deep tendon reflex.
Adequate telemedical history taking and physical examination performance depend on the patient, availability of an assistant, and the assistant’s level of training. A hands-on educational curriculum to train assistants has the potential to narrow the gap between in-person and telemedicine examinations. This could substantially increase access to higher-level expert evaluations across the United States and internationally. More research regarding training, costs, implementation, and outcome measures for such assistants is warranted. As telemedicine continues to grow rapidly, the field must remain proactive, flexible, and nimble in using all resources to improve quality, access, and value to our patients.
Detailed breakdown of the neurological examination elements laid out in
advanced practice providers
Our thanks to Drs Sameer Ali, Yi Mao, and Thomas Hurlbutt for their thoughtful feedback.
IB designed and conceptualized the paper and drafted and revised the manuscript for intellectual content. DTC drafted and reviewed the manuscript for intellectual content.
None declared.