The past, present, and future of telemedicine for Parkinson's disease

Tele-Neuro-Rehabilitation in Italy: State of the Art and Future Perspectives

Current research suggests that the management of neurological diseases, both in adults and children, requires an ever increasing commitment of resources for the national healthcare system (NHS). In Italy, due to the aging of the population, increase in chronicity and morbidity of pathologies, and presence of islands and rural areas, health needs to be supported by innovative technologies. Telemedicine is a method of providing healthcare services at distance, remotely connecting health professionals and patients (or two professionals). In Italy, telemedicine is under development, and the NHS has not yet exploited and independently developed all the possibilities that telemedicine offers. Tele-rehabilitation consists in the use of information and communication technologies for the remote support of rehabilitation services. By allowing “home care,” it represents a valid support during the home rehabilitation process. This review is aimed at evaluating the role of telerehabilitation in Italy, with regard to the motor and cognitive rehabilitation programs applied to neurological pathologies, in both pediatric and adult patients. We screened the studies published between 2010 and 2019 on PubMed, Scopus, Cochrane, and Web of Sciences databases. Using the PICO model, the search combined the terms “telerehabilitation”; “neurological disorders”; “neurodegenerative disease,” “motor telerehabilitation”; “cognitive rehabilitation.” This review showed that telerehabilitation is a promising healthcare tool, as it guarantees continuity of care over time (after discharge) and in space (from hospital to patient's home), especially in patients with stroke. Furthermore, it allows to increase the frequency and intensity of rehabilitation programs, provide individualized rehabilitation treatment in comfortable and familiar environment for patient, monitor and evaluate patients' needs and progress, stimulate patient motivation and achieve better patient satisfaction, verify the results achieved by the patients, and potentially reduce the service costs. Unfortunately, almost all neurorehabilitation studies are characterized by small samples and wide variability of results, and would benefit from standardized procedures, aims and targets. Future telerehabilitation trials should include cost-effectiveness analysis associated with clinical outcomes to better assess the validity of this promising tool.

A New Day: The Role of Telemedicine in Reshaping Care for Persons With Movement Disorders

The COVID-19 pandemic has demonstrated the fragility of clinic-based care for Parkinson's disease and other movement disorders. In response to the virus, many clinics across the world abruptly closed their doors to persons with Parkinson's disease. Fortunately, a niche care model, telemedicine-first described in this journal a generation ago-emerged as the dominant means of providing care. As we adjust to a new normal, we should focus future care not on clinics but on patients. Their needs, guided by clinicians, should determine how care is delivered, whether in the clinic, at home, remotely, or by some combination. Within this patient-centered approach, telemedicine is an attractive care option but not a complete replacement for in-person consultations, which are valuable for specific problems and for those who have access. Now that many clinicians and patients have gained exposure to telemedicine, we can better appreciate its advantages (eg, convenience) and disadvantages (eg, restricted examination). We can also create a new future that utilizes the Internet, video conferencing, smartphones, and sensors. This future will bring many clinicians to one patient, connect individual experts to countless patients, use widely available devices to facilitate diagnosis, and apply novel technologies to measure the disease in new ways. These approaches, which extend to education and research, enable a future where we can care for anyone anywhere and will help us stem the tide of Parkinson's disease. © 2020 International Parkinson and Movement Disorder Society.

Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2)

Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.

Care, Convenience, Comfort, Confidentiality, and Contagion: The 5 C's that Will Shape the Future of Telemedicine

The COVID-19 pandemic has driven rapid, widespread adoption of telemedicine. The distribution of clinicians, long travel distances, and disability all limit access to care, especially for persons with Parkinson's disease. Telemedicine is not a panacea for all of these challenges but does offer advantages. These advantages can be summarized as the 5 C's: accessible care, increased convenience, enhanced comfort, greater confidentiality to patients and families, and now reduced risk of contagion. Telemedicine also has its limitations, including the inability to perform parts of the physical examination and inequitable access to the Internet and related technologies. Future models will deliver care to patients from a diverse set of specialties. These will include mental health specialists, physiotherapists, neurosurgeons, speech-language therapists, dieticians, social workers, and exercise coaches. Along with these new care models, digital therapeutics, defined as treatments delivered through software programs, are emerging. Telemedicine is now being introduced as a bridge to restart clinical trials and will increasingly become a normal part of future research studies. From this pandemic will be a wealth of new telemedicine approaches which will fundamentally change and improve care as well as research for individuals with Parkinson's disease.

A cost-consequence analysis comparing patient travel, outreach, and telehealth clinic models for a specialist diabetes service to Indigenous people in Queensland

INTRODUCTION

The delivery of specialist health services to people living in Indigenous communities is an important challenge. Specialist diabetes outpatient clinics may be delivered via a patient travelling to a metropolitan hospital, during an outreach clinic, or by telehealth. The aim of this study was to compare the costs and consequences of different service models for delivering specialist diabetes clinics for a remote Indigenous community.

METHOD

Patient travel, outreach and telehealth clinic models were compared using a cost-consequence analysis principles. The setting was Cunnamulla, a remote Indigenous community in Western Queensland. Costs were calculated by quantifying the staff resources and travel costs for each clinic model. Costs were reported in Australian dollars and reported from the health service perspective.

RESULTS

The marginal cost per patient for each clinic were $692 for patient travel, $482 for the outreach and $284 for telehealth. If a patient travel appointment was replaced with telehealth, approximately $517 in costs for patient travel reimbursement would be avoided. While replacing an entire outreach clinic with a telehealth clinic would reduce costs by approximately $3961.

CONCLUSION

The marginal cost of patient travel to a metropolitan clinic and outreach clinic appointments was greater than telehealth. Telehealth is unlikely to completely replace the need for patient travel or outreach clinics. However, replacing a proportion of these appointments with telehealth may reduce the overall costs of providing specialist diabetes care in remote communities. Telehealth may have advantages beyond economic as it reduces the time away from usual activities for both the patient and endocrinologist.

Exploring how virtual primary care visits affect patient burden of treatment

BACKGROUND

There is growing emphasis on the role of digital solutions in supporting chronic disease management. This has the potential to increase the burden patients experience in managing their health by offloading care from the health system to patients. This paper explores the effects of virtual visits on patient burden using an explicit framework measuring both the work patients do to care for their health and the challenges they experience that exacerbate burden.

METHODS

This mixed methods study evaluates a large pilot implementation of virtual visits (video, audio, and asynchronous messaging with providers) in primary care in Ontario, Canada. Participants were recruited using convenience sampling from patients using a virtual visit platform to complete a semi-structured interview or a survey including a free-text response. We conducted 17 interviews and reviewed 427 free text responses related to explore patients' perceived value and burden of these visits. We used qualitative analyses to map patients' feedback on their experience to the framework on patient burden.

MAIN FINDINGS

Virtual visits appear to reduce the work patients must do to manage their care by 1) improving access, convenience, and time needed for medical appointments, and 2) making it easier to access information and support for chronic disease management. Virtual visits also alleviate patients' perceived burden by improving continuity of care, experience of care, and providing some cost savings.

CONCLUSIONS

Virtual visits reduced overall patient burden of treatment by decreasing the required patient effort of managing medical appointments and monitoring their health, and by minimizing challenges experienced when accessing care. For regions that want to improve patient experience of care, virtual visits are likely to be of benefit. There is need for further research on the generalizability of the findings herein, particularly for high-needs populations under-represented such as those of low socioeconomic status and those in rural and remote locations.

Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.

Design and Operation of the Lombardy Parkinson's Disease Network

Background: Parkinson's disease (PD) is one of the most common chronic neurological conditions leading to disability and social burden. According to the 2016 Italian National Plan on Chronic Diseases, regional health authorities are implementing dedicated networks to manage neurological diseases, including PD.

Methods: A panel of experts representing health-care providers in Lombardy reached consensus on the organization of a patient-centered regional PD healthcare network.

Results: The panel proposed a structure and organization implementing a hub-and-spoke PD network model. Three levels of neurological services were identified: General Neurologist, PD Clinic, PD Center. This model was applied to health service providers currently accredited in Lombardy, yielding 12 candidate PD Centers, each serving an area of ~1,000–2,000 km², and not less than 27 PD Clinics. The panel agreed on uniform diagnostic and staging criteria for PD, and on a minimum common clinical data set, on PD patient management by the network at initial and follow-up assessments, on the cadence of follow-up visits, on patient referrals, and on outcome measures for the assessment of network activities.

Conclusions: The implementation of disease-centered networks for chronic neurological diseases provides an innovative opportunity to improve patient management, facilitate research and education.

Patient-Centric Care for Parkinson's Disease: From Hospital to the Community

Parkinson's disease (PD) is a chronic neurodegenerative disease with complex motor and non-motor symptoms often leading to significant caregiver burden. An integrated, multidisciplinary care setup involving different healthcare professionals is the mainstay in the holistic management of PD. Many challenges in delivering multidisciplinary team (MDT) care exist, such as insufficient expertise among different healthcare professionals, poor interdisciplinary collaboration, and communication. The need to attend different clinics, incurring additional traveling and waiting time for allied health therapies can also make MDT care more burdensome. By shifting MDT care to local community settings and into patients' homes, patient-centered care can be achieved. In Singapore, the National Neuroscience Institute created the Community Care Partners Programme in 2007 to bring the allied MDT team to the community and nurse-led Integrated Community Care Programme for Parkinson's Disease in 2012 to provide care in community and at patient's home. However, attaining MDT care in the community setting is difficult to achieve where there is a shortage of PD-trained professionals. As such, interdisciplinary and transdisciplinary management would be other best practice options to deliver patient-centric care in PD. Telemedicine could be another viable option to bring the MDT closer to the patient.

Patient Views on Telemedicine for Parkinson Disease

BACKGROUND

Telemedicine is increasingly used for Parkinson disease, but the perspectives of persons with Parkinson disease have not been systematically assessed.

METHODS

We therefore conducted a national online survey, and 781 individuals with Parkinson disease responded.

RESULTS

Of these, 76% indicated high interest, and 29% reported prior telemedicine experience. The top advantages included access to specialists (62%), convenience (60%), and time savings (59%). The most common disadvantages were the lack of hands-on care (69%), lack of intimacy (43%), and technical difficulties (37%).

CONCLUSIONS

In this non-representative sample, interest in telemedicine was high but tempered by the concern for loss of high touch care.

Role of data measurement characteristics in the accurate detection of Parkinson's disease symptoms using wearable sensors

Background

Parkinson’s disease (PD) is a progressive neurological disease, with characteristic motor symptoms such as tremor and bradykinesia. There is a growing interest to continuously monitor these and other symptoms through body-worn sensor technology. However, limited battery life and memory capacity hinder the potential for continuous, long-term monitoring with these devices. There is little information available on the relative value of adding sensors, increasing sampling rate, or computing complex signal features, all of which may improve accuracy of symptom detection at the expense of computational resources. Here we build on a previous study to investigate the relationship between data measurement characteristics and accuracy when using wearable sensor data to classify tremor and bradykinesia in patients with PD.

Methods

Thirteen individuals with PD wore a flexible, skin-mounted sensor (collecting tri-axial accelerometer and gyroscope data) and a commercial smart watch (collecting tri-axial accelerometer data) on their predominantly affected hand. The participants performed a series of standardized motor tasks, during which a clinician scored the severity of tremor and bradykinesia in that limb. Machine learning models were trained on scored data to classify tremor and bradykinesia. Model performance was compared when using different types of sensors (accelerometer and/or gyroscope), different data sampling rates (up to 62.5 Hz), and different categories of pre-engineered features (up to 148 features). Performance was also compared between the flexible sensor and smart watch for each analysis.

Results

First, there was no effect of device type for classifying tremor symptoms (p > 0.34), but bradykinesia models incorporating gyroscope data performed slightly better (up to 0.05 AUROC) than other models (p = 0.01). Second, model performance decreased with sampling frequency (p < 0.001) for tremor, but not bradykinesia (p > 0.47). Finally, model performance for both symptoms was maintained after substantially reducing the feature set.

Conclusions

Our findings demonstrate the ability to simplify measurement characteristics from body-worn sensors while maintaining performance in PD symptom detection. Understanding the trade-off between model performance and data resolution is crucial to design efficient, accurate wearable sensing systems. This approach may improve the feasibility of long-term, continuous, and real-time monitoring of PD symptoms by reducing computational burden on wearable devices.

Telemedicine for Hyperkinetic Movement Disorders

Telemedicine is the use of electronic communication technology to facilitate healthcare between distant providers and patients. In addition to synchronous video conferencing, asynchronous video transfer has been used to support care for neurology patients.

There is a growing literature on using telemedicine in movement disorders, with the most common focus on Parkinson’s disease. There is accumulating evidence for videoconferencing to diagnose and treat patients with hyperkinetic movement disorders and to support providers in remote underserviced areas. Cognitive testing has been shown to be feasible remotely. Genetic counseling and other counseling-based therapeutic interventions have also successfully performed in hyperkinetic movement disorders.

We use a problem-based approach to review the current evidence for the use of telemedicine in various hyperkinetic movement disorders. This Viewpoint attempts to identify possible telemedicine solutions as well as discussing unmet needs and future directions.

Interdisciplinary palliative care for people with advanced Parkinson's disease: a view from the home

BACKGROUND

Advanced Parkinson's disease (PD) is a multidimensional neurodegenerative condition with motor and non-motor symptoms contributing to increasing disability and decreasing quality of life. As the disease progresses, patients may become homebound and estranged from neurological care, with dire consequences. We describe the increasing epidemiologic burden of and individual risks faced by patients with palliative-stage PD and their caregivers.

METHODS

With the aim of mitigating these risks, we designed and iterated two models of interdisciplinary home visits to maintain continuity of care and illuminate the unmet needs and barriers to care faced by this population. We describe both models in detail, with data on feasibility and patient-centered outcomes achieved in the initial model, and baseline characteristics of participants in the ongoing expanded model. Finally, we illustrate the scope and common themes of such palliative care-informed home visits with two cases.

RESULTS

The pilot model involved over 380 visits with 109 individual patients. Among those patients, PD severity worsened by nearly 12 points annually on the Unified Parkinson's Disease Rating Scale (UPDRS), without a corresponding decline in quality of life. In an ongoing study of the second iteration of the model, 52 patient-caregiver dyads have completed their initial visit, with 44% bearing a diagnosis of dementia and the majority requiring an assistive device or being bedbound. Two cases highlight the critical importance of thorough medication reconciliation and home safety assessment in the comprehensive evaluation and management of such patients.

CONCLUSIONS

As our population ages, therapies increase, and the number of individuals living with advanced PD and related disorders grows, so too does the imperative to recognize and address the palliative care needs of such patients and families. For many, home may be a viable, and perhaps optimal, site for this care.

Multidisciplinary Care to Optimize Functional Mobility in Parkinson Disease

This review elaborates on multidisciplinary care for persons living with Parkinson disease by using gait and balance impairments as an example of a treatable target that typically necessitates an integrated approach by a range of different and complementary professional disciplines. Using the International Classification of Functioning, Disability, and Health model as a framework, the authors discuss the assessment and multidisciplinary management of reduced functional mobility due to gait and balance impairments. By doing so, they highlight the complex interplay between motor and nonmotor symptoms, and their influence on rehabilitation. They outline how multidisciplinary care for Parkinson disease can be organized.

Tele-monitored tDCS rehabilitation: feasibility, challenges and future perspectives in Parkinson's disease

Transcranial direct current stimulation (tDCS) is a modality of non-invasive brain stimulation involving the application of low amplitude direct current via surface electrodes on the scalp. tDCS has been studied in healthy populations and in multiple brain disorders and has the potential to be a treatment for several neuropsychiatric conditions by virtue of its capability of influencing cognitive, motor and behavioral processes. tDCS is a generally safe technique when performed within standardized protocols in research or clinical settings. Furthermore, tDCS portability, high acceptability and user-friendly interface makes it highly appealing for telemedicine practices. The term "telemedicine" refers to the procedures, educational strategies, and care services that are remotely administered by means of different communication technologies, with the final goal of increasing access to care for individuals and for improving public health. The use of telemedicine combined with tDCS protocols is increasing, although the safety of this approach in different clinical settings awaits further assessment. While "do-it-yourself" tDCS should be discouraged due to the unknown risk of adverse events, the implementation of tele-monitored tDCS (tele-tDCS) within standardized frameworks ensuring safety, tolerability, and reproducibility may allow this technology to reach larger clinical populations and bypass some of the common barriers preventing access to health services and clinical trials. This review will discuss the current evidence supporting the feasibility of tele-tDCS paradigms and their therapeutic potential, with particular emphasis on the implications for patients with Parkinson's disease.

A Randomized Crossover Pilot Study of Telemedicine Delivered via iPads in Parkinson's Disease

Background

We investigated the feasibility and safety of a video-based telemedicine system, delivered via a tablet, in Parkinson's disease (PD).

Methods

In a randomized, crossover, open-label pilot trial, we compared a telemedicine period (regular visits every two months with intermediate video calls via an iPad mini) with a control period (regular visits every two months), both lasting 6 months. We included 10 patients diagnosed with PD according to the British Brain Bank criteria, aged 20–75 years. The primary outcome was the PD questionnaire summary index (PDQ-39 SI). Secondary outcomes included the Hoehn and Yahr Stage and scores on the Unified PD Rating Scale (UPDRS) part I–IV, Beck Depression Inventory (BDI), and visual analog scale for satisfaction.

Results

Both study periods were completed by 10 patients with PD. Friedman's test revealed that there were no significant differences between the two periods in primary and secondary outcomes (p > 0.05). With respect to visual analog scale scores for satisfaction, participants indicated high satisfaction with the telemedicine system. The number of extra hospital visits and phone calls did not differ between the periods. There were no adverse events or side effects.

Conclusions

We observed that a telemedicine system delivered via a tablet could successfully be used by patients as a part of their care. Further studies investigating the use of telemedicine to replace in-person visits are warranted. This trial is registered with UMIN000015536.

Automated Deep Brain Stimulation Programming for Tremor

Deep brain stimulation (DBS) programming, the systematic selection of fixed electrical stimulation parameters that deliver maximal therapeutic benefit while limiting side effects, poses several challenges in the treatment of movement disorders. DBS programming requires the expertise of trained neurologists or nurses who assess patient symptoms according to standardized clinical rating scales and use patient reports of DBS-related side effects to adjust stimulation parameters and optimize therapy. In this paper, we describe and validate an automated software platform for DBS programming for tremor associated with Parkinson's disease and essential tremor. DBS parameters are changed automatically through a direct computer interface with implanted neurostimulators. Each tested DBS setting is ranked according to its effect on tremor, which is assessed using smartwatch inertial measurement unit data, and side effects, which are reported through a user interface. Blinded neurologist assessments showed the automated programming method performed at least as well as clinician mediated programming in selecting the optimal settings for tremor therapy. This proof of concept study describes a novel DBS programming paradigm that may improve programming efficiency and outcomes, increase access to programming outside specialty clinics, and aid in the development of adaptive and closed-loop DBS strategies.

Personalized Telemedicine for Depression in Parkinson's Disease: A Pilot Trial

High rates of depression are observed in Parkinson's disease, and limited access to care complicates management. The purpose of this pilot project was to evaluate the feasibility and impact of a personalized cognitive-behavioral telemedicine program for depression in Parkinson's disease (dPD). Thirty-four individuals with dPD and their carepartners participated in this pilot study. A 10-module self-help workbook, tailored to the unique needs of the dPD population, was created to be used as either a stand-alone intervention, with minimal therapist support, or a supplement to formal telephone-administered cognitive-behavioral therapy sessions. Improvements in depression, anxiety, quality of life, sleep, negative thoughts, and caregiver burden were observed over the course of the 4-month study, independent of treatment modality (guided self-help vs formal telephone-based psychotherapy). Future research will utilize randomized controlled designs and continue to focus on delivery models that can improve access to this and other evidence-based mental health interventions for dPD.

Digital technologies for social inclusion of individuals with disabilities

Information technology can be an important facilitator of social inclusion for people with disabilities into society. However, the goals specified in this area by organizations such as the European Commission have not yet been achieved in their totality. The aim of this paper is to explore which types of information communication technology-based applications and/or digital services have been suggested to facilitate the social integration of people who suffer from different types of disabilities. We performed a literature review that included studies published during a period of 6 years (2010–2016). The results show that, in the data we have had access to, no concrete patterns can be identified regarding the type of technology or technological trends that can be used to support the social integration of individuals with disabilities. This literature review is of relevance to the identification of further research areas and to the identification of issues which have to be considered in the context of the development and implementation of technological innovations that are aimed at promoting or facilitating social inclusion of individuals with disabilities.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

The Promise of Telemedicine for Movement Disorders: an Interdisciplinary Approach

PURPOSE OF REVIEW

Advances in technology have expanded telemedicine opportunities covering medical practice, research, and education. This is of particular importance in movement disorders (MDs), where the combination of disease progression, mobility limitations, and the sparse distribution of MD specialists increase the difficulty to access. In this review, we discuss the prospects, challenges, and strategies for telemedicine in MDs.

RECENT FINDINGS

Telemedicine for MDs has been mainly evaluated in Parkinson's disease (PD) and compared to in-office care is cost-effective with similar clinical care, despite the barriers to engagement. However, particular groups including pediatric patients, rare MDs, and the use of telemedicine in underserved areas need further research. Interdisciplinary telemedicine and tele-education for MDs are feasible, provide similar care, and reduce travel costs and travel time compared to in-person visits. These benefits have been mainly demonstrated for PD but serve as a model for further validation in other movement disorders.

Multilingual website and cyberconsultations for oromandibular dystonia

Oromandibular dystonia is a focal dystonia that manifests as involuntary masticatory and/or tongue muscle contractions. This movement disorder is frequently misdiagnosed as a temporomandibular disorder. Hence, it would be useful to establish a method that makes it possible for patients with the condition to find appropriate medical institutions by themselves. The author produced a website Involuntary movements of the stomatognathic region (https://sites. google.com/site/oromandibulardystoniaenglish/) for patients with oromandibular dystonia, which is available in twenty languages. It has been viewed more than 1,000,000 times by individuals from all over the world. The visitors to the site have completed questionnaires and/or sent images or videos of their involuntary movements over the internet. Cyberconsultations (remote diagnosis) were also performed via Skype^™. Approximately 1000 patients with involuntary stomatognathic movements visited our department. Only 12.5% of the patients had previously been diagnosed with or were suspected to have dystonia. The findings of this study suggest that the multilingual website has contributed to increasing awareness of oromandibular dystonia and that the provision of basic telemedicine via the internet can aid the diagnosis and treatment of oromandibular dystonia.

Hypertension and Diagnosis of Parkinson's Disease: A Meta-Analysis of Cohort Studies

Background

Hypertension has been associated with cognitive dysfunction in the general population and patients with Alzheimer's disease (AD). However, there are contradictory data regarding the potential association between hypertension and diagnosis of Parkinson's disease (PD), the second most common neurodegenerative disorder after AD. The purpose of this meta-analysis is to synthesize data from cohort studies to explore the potential association between preexisting hypertension and subsequent PD diagnosis.

Methods

The PubMed and Embase databases were searched to identify all relevant studies. Two independent investigators performed the data extraction. Eligible cohort studies providing risk and precision estimates related to hypertension and PD were selected. Pooled risk ratios (RRs) with 95% confidence interval (CI) were calculated by using a random-effects model or a fixed-effects model. Sensitivity analyses after excluding one study at a time were performed to assess the stability of the results. Publication bias was assessed with Begg's test and Egger's test.

Results

Seven cohort studies were identified, including 3,170 persons who were confirmed to have developed PD and 339,517 participants who did not have PD during follow-up. The onset of hypertension before PD diagnosis was significantly associated with an increased risk of motor stage PD (RR = 1.799, 95% CI [1.066-3.037]). This relationship was further confirmed by secondary analyses based on estimates adjusted for potential vascular confounders (RR = 1.319, 95% CI [1.073-1.622]). After excluding one study at a time, the sensitivity analyses still showed that hypertension history was significantly associated with an increased risk of motor stage PD (RR with 95% CI ranging from 1.11 [1.075-1.35] to 1.42 [1.65-1.83]). No publication bias was observed in this meta-analysis.

Conclusion

The findings of this meta-analysis suggest that hypertension may be a risk factor for motor stage PD, which may provide novel insights into the etiology and pathogenesis of this neurodegenerative disorder. However, large-scale well-designed studies that consider various confounders are still needed to further verify and clarify the association between hypertension and PD diagnosis.

Freezing of gait: Promising avenues for future treatment

Freezing of gait is a devastating symptom of Parkinson's disease and other forms of parkinsonism. It poses a major burden on both patients and their families, as freezing often leads to falls, fall-related injuries and a loss of independence. Treating freezing of gait is difficult for a variety of reasons: it has a paroxysmal and unpredictable nature; a multifaceted pathophysiology, with an interplay between motor elements (disturbed stepping mechanisms) and non-motor elements (cognitive decline, anxiety); and a complex (and likely heterogeneous) underlying neural substrate, involving multiple failing neural networks. In recent years, advances in translational neuroscience have offered new insights into the pathophysiology underlying freezing. Furthermore, the mechanisms behind the effectiveness of available treatments (or lack thereof) are better understood. Driven by these concepts, researchers and clinicians have begun to improve currently available treatment options, and develop new and better treatment methods. Here, we evaluate the range of pharmacological (i.e. closed-looped approaches), surgical (i.e. multi-target and adaptive deep brain and spinal cord stimulation) and behavioural (i.e. biofeedback and cueing on demand) treatment options that are under development, and propose novel avenues that are likely to play a crucial role in the clinical management of freezing of gait in the near future. The outcomes of this review suggest that the successful future management of freezing of gait will require individualized treatments that can be implemented in an on-demand manner in response to imminent freezing. With this review we hope to guide much-needed advances in treating this devastating symptom of Parkinson's disease.

Teleneurology for Veterans in a Major Metropolitan Area

BACKGROUND

The recent growth in telehealth has been facilitated by the need to deliver healthcare to patients living in remote or rural areas. In contrast, the role of telehealth in more urban settings is less clear. A teleneurology program was established in 2011 at the Tibor Rubin VA Medical Center (TRVAMC) in Long Beach, California. A review of teleneurology encounters was conducted to assess the feasibility of applying this telehealth modality to patients with chronic neurological disorders living in an urban setting.

METHODS

Teleneurology encounters were conducted by clinical video telehealth (CVT) between a provider at the TRVAMC and patients at local community-based outpatient clinics from November 2011 to December 2014. In a random sampling of veterans, they were asked to complete a patient satisfaction survey.

RESULTS

A total of 745 teleneurology encounters were performed including 570 unique patients. Veterans with a broad range of neurological disorders were seen, including Parkinson's disease, headaches, epilepsy, dementia, cerebrovascular disease, peripheral nervous system disorders, multiple sclerosis, and other problems such as dizziness and paresthesia. Compared with patients in face-to-face clinics, patients in teleneurology clinics consistently kept their appointments. Technical problems were rare and easily resolved. The majority of patients were satisfied with the care they received through teleneurology, and preferred CVT rather than a face-to-face encounter.

CONCLUSIONS

This report demonstrates the successful application of telehealth to evaluate and manage a diverse group of neurological disorders in an urban setting. Despite the relatively short distances involved, the majority of patients preferred telehealth over face-to-face encounters.

Virtual Reality Telerehabilitation for Postural Instability in Parkinson's Disease: A Multicenter, Single-Blind, Randomized, Controlled Trial

Introduction

Telerehabilitation enables patients to access remote rehabilitation services for patient-physiotherapist videoconferencing in their own homes. Home-based virtual reality (VR) balance training has been shown to reduce postural instability in patients with Parkinson's disease (PD). The primary aim was to compare improvements in postural stability after remotely supervised in-home VR balance training and in-clinic sensory integration balance training (SIBT).

Methods

In this multicenter study, 76 PD patients (modified Hoehn and Yahr stages 2.5–3) were randomly assigned to receive either in-home VR telerehabilitation (n = 38) or in-clinic SIBT (n = 38) in 21 sessions of 50 minutes each, 3 days/week for 7 consecutive weeks. VR telerehabilitation consisted of graded exergames using the Nintendo Wii Fit system; SIBT included exercises to improve postural stability. Patients were evaluated before treatment, after treatment, and at 1-month follow-up.

Results

Analysis revealed significant between-group differences in improvement on the Berg Balance Scale for the VR telerehabilitation group (p = 0.04) and significant Time × Group interactions in the Dynamic Gait Index (p = 0.04) for the in-clinic group. Both groups showed differences in all outcome measures over time, except for fall frequency. Cost comparison yielded between-group differences in treatment and equipment costs.

Conclusions

VR is a feasible alternative to in-clinic SIBT for reducing postural instability in PD patients having a caregiver.

Validation of a Smartphone Application Measuring Motor Function in Parkinson's Disease

BACKGROUND

Measurement of motor function is critical to the assessment and management of Parkinson's disease. Ambulatory motor assessment has the potential to provide a glimpse of the patient's clinical state beyond the consultation. We custom-designed a smartphone application that quantitatively measures hand dexterity and hypothesized that this can give an indication of a patient's overall motor function.

OBJECTIVE

The aims of this study were to (i) validate this smartphone application against MDS-UPDRS motor assessment (MDS-UPDRS-III) and the two-target tapping test; (ii) generate a prediction model for MDS-UPDRS-III; (iii) assess repeatability of our smartphone application and (iv) examine compliance and user-satisfaction of this application.

METHODS

103 patients with Parkinson's disease were recruited from two movement disorders clinics. After initial assessment, a group of patients underwent repeat assessment within two weeks. Patients were invited to use the smartphone application at home over three days, followed by a survey to assess their experience.

RESULTS

Significant correlation between key smartphone application test parameters and MDS-UPDRS-III (r = 0.281-0.608, p < 0.0001) was demonstrated. A prediction model based on these parameters accounted for 52.3% of variation in MDS-UPDRS-III (R2 = 0.523, F(4,93) = 25.48, p < 0.0001). Forty-eight patients underwent repeat assessment under identical clinical conditions. Repeatability of key smartphone application tests parameters and predicted MDS-UPDRS-III was moderate to strong (intraclass correlation coefficient 0.584-0.763, p < 0.0001). The follow-up survey identified that our patients were very comfortable with the smartphone application and mobile technology.

CONCLUSIONS

Our smartphone application demonstrated satisfactory repeatability and validity when measured against MDS-UPDRS-III. Its performance is acceptable considering our smartphone application measures hand dexterity only.

Telemedicine Enables Broader Access to Movement Disorders Curricula for Medical Students

Background

The impact of tele-education for movement disorders on medical students is unknown. The present study had three objectives. First, to create a tele-education program for medical students in regions with limited access to movement disorders curricula. Second, to analyze the feasibility, satisfaction, and improvement of medical knowledge. Third, to assess the main reasons of medical students for attending this course.

Methods

In 2016, a program was piloted in a low-middle income (Cameroon) and a middle-high income (Argentina) country. Medical students were offered a free movement disorder tele-education program (four medical schools in Argentina, and 1 medical school in Cameroon). Six real-time videoconferences covering hyperkinetic and hypokinetic movement disorders were included. Evaluations included attendance, pre- and post-medical knowledge, and satisfaction questionnaires.

Results

The study included 151 undergraduate medical students (79.4% from Argentina, 20.6% from Cameroon). Feasibility was acceptable with 100% and 85.7% of the videoconferences completed in Argentina and Cameroon, respectively. Attendance was higher in Argentina compared to Cameroon (75% vs. 33.1%). According to student reports, the topics and innovative educational environment were the main reasons for attendance. Both groups ranked satisfaction as moderate to high, and medical knowledge improved similarly in both countries.

Discussion

Tele-education can improve movement disorders knowledge in medical schools in high-middle and low-middle income countries lacking access to other educational opportunities.

Making a measurable difference in advanced Huntington disease care

Neurologists' role in the care of people with advanced Huntington disease (HD) (total functional capacity <7), often limited by a lack of clinical research to support good practice, includes the following: (1) provide comprehensive health records to an interdisciplinary care staff before admission to a more intense care setting (home health services, day program, assisted living, group home, long-term skilled nursing facility, palliative care); (2) consult with and refer to rehabilitation (occupational therapy, physical therapy, speech and language pathology), behavioral and psychiatric professionals for problem-solving strategies, which must be reviewed with direct care staff before implementation; (3) encourage and support qualitative and quantitative interdisciplinary research studies, and randomized controlled studies of nonpharmacologic interventions; and (4) assist in the development of meaningful measures to further document what works to provide a good quality of life for the patient and family and a comfortable thoughtful approach to a good death. Collaborative models of care depend on: (1) clear communication; (2) ongoing education and support programs; with (3) pharmacologic and rehabilitation interventions, always in the context of respect for the person with HD, a preservation of the individuals' dignity, autonomy, and individual preferences.

Complement receptor 3 mediates NADPH oxidase activation and dopaminergic neurodegeneration through a Src-Erk-dependent pathway

Microglial NADPH oxidase (Nox2) plays a key role in chronic neuroinflammation and related dopaminergic neurodegeneration in Parkinson's disease (PD). However, the mechanisms behind Nox2 activation remain unclear. Here, we revealed the critical role of complement receptor 3 (CR3), a microglia-specific pattern recognition receptor, in Nox2 activation and subsequent dopaminergic neurodegeneration by using paraquat and maneb-induced PD model. Suppression or genetic deletion of CR3 impeded paraquat and maneb-induced activation of microglial Nox2, which was associated with attenuation of dopaminergic neurodegeneration. Mechanistic inquiry revealed that blocking CR3 reduced paraquat and maneb-induced membrane translocation of Nox2 cytosolic subunit p47^phox, an essential step for Nox2 activation. Src and Erk (extracellular regulated protein kinases) were subsequently recognized as the downstream signals of CR3. Moreover, inhibition of Src or Erk impaired Nox2 activation in response to paraquat and maneb co-exposure. Finally, we found that CR3-deficient mice were more resistant to paraquat and maneb-induced Nox2 activation and nigral dopaminergic neurodegeneration as well as motor dysfunction than the wild type controls. Taken together, our results showed that CR3 regulated Nox2 activation and dopaminergic neurodegeneration through a Src-Erk-dependent pathway in a two pesticide-induced PD model, providing novel insights into the immune pathogenesis of PD.

National randomized controlled trial of virtual house calls for Parkinson disease

OBJECTIVE

To determine whether providing remote neurologic care into the homes of people with Parkinson disease (PD) is feasible, beneficial, and valuable.

METHODS

In a 1-year randomized controlled trial, we compared usual care to usual care supplemented by 4 virtual visits via video conferencing from a remote specialist into patients' homes. Primary outcome measures were feasibility, as measured by the proportion who completed at least one virtual visit and the proportion of virtual visits completed on time; and efficacy, as measured by the change in the Parkinson's Disease Questionnaire-39, a quality of life scale. Secondary outcomes included quality of care, caregiver burden, and time and travel savings.

RESULTS

A total of 927 individuals indicated interest, 210 were enrolled, and 195 were randomized. Participants had recently seen a specialist (73%) and were largely college-educated (73%) and white (96%). Ninety-five (98% of the intervention group) completed at least one virtual visit, and 91% of 388 virtual visits were completed. Quality of life did not improve in those receiving virtual house calls (0.3 points worse on a 100-point scale; 95% confidence interval [CI] -2.0 to 2.7 points; p = 0.78) nor did quality of care or caregiver burden. Each virtual house call saved patients a median of 88 minutes (95% CI 70-120; p < 0.0001) and 38 miles per visit (95% CI 36-56; p < 0.0001).

CONCLUSIONS

Providing remote neurologic care directly into the homes of people with PD was feasible and was neither more nor less efficacious than usual in-person care. Virtual house calls generated great interest and provided substantial convenience.

CLINICALTRIALSGOV IDENTIFIER

NCT02038959.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients with PD, virtual house calls from a neurologist are feasible and do not significantly change quality of life compared to in-person visits. The study is rated Class III because it was not possible to mask patients to visit type.

Nonmotor Symptoms and Natural History of Parkinson's Disease: Evidence From Cognitive Dysfunction and Role of Noninvasive Interventions

Parkinson's disease (PD) is a common neurodegenerative disorder, characterized by motor and nonmotor symptoms (NMS). Several subsequent studies substantiate the great functional burden related to NMS, their progression, and negative effect on quality of life in PD. Additional evidence indicates interesting relationships between striatal dopaminergic function and NMS. The basal ganglia are implicated in the modulation and integration of sensory information and pain, bladder function is under control of both inhibitory (D1) and facilitatory (D2) dopaminergic inputs, finally reduced dopaminergic activity in the mesocortical and mesolimbic pathways is involved in the development of several NMS including mood, motivational, and cognitive alterations. Some NMS fluctuate in response to dopaminergic treatment and are relieved by dopamine replacement therapy, other are insensitive to current therapeutic strategies. The relation among the overall disease complications, perhaps the most important for PD patients and family members' well-being and functionality is dementia that affects most PD patients over the course of disease. Specific pharmacological treatment is lacking, and alternative approaches have been implemented to improve everyday functionality and quality of life. The state of the art suggests that cognitive rehabilitation in PD is possible and may either increase performance or preserve cognitive level over the time. However, it is also evident that cognitive abnormalities in PD are heterogeneous and we still do not have biomarkers to detect early patients at risk for dementia. Cognitive dysfunction is one the most prevalent NMS and is a clinically and functionally important disease milestone. Given the available clinical and imaging evidence it is possible to use cognition to model NMS progression and design nonpharmacological interventions. In this chapter we will address the use of cognitive rehabilitation and noninvasive brain stimulation techniques to modulate cognitive performance and rescue connectivity in affected brain circuitry.

Virtual visits for Parkinson disease: A multicenter noncontrolled cohort

BACKGROUND

Previous small-scale studies have demonstrated the feasibility of providing remote specialty care via virtual visits. We assessed the feasibility and benefits of a one-time consultation between a remote Parkinson Disease (PD) specialist and an individual with PD at home on a larger scale.

METHODS

We conducted a multicenter noncontrolled cohort of virtual visits administered over videoconferencing between remote PD specialists and individuals with PD in their home. Specialists performed a patient history and a PD-specific physical examination and provided recommendations to patients and their local physicians. The primary outcome measures were feasibility, as measured by the proportion of visits completed as scheduled, and the 6-month change in quality of life, as measured by the Parkinson's Disease Questionnaire 39. Additional outcomes included satisfaction with visits and interest in future virtual visits.

RESULTS

A total of 277 participants from 5 states enrolled, 258 participants completed virtual visits with 14 different physicians, and 91% of visits were completed as scheduled. No improvement in quality of life was observed at 6 months (0.4-point improvement; 95% confidence interval -1.5 to 0.6; p = 0.39). Overall satisfaction with virtual visits was high among physicians (94% satisfied or very satisfied) and patients (94% satisfied or very satisfied), and 74% of participants were interested in receiving future care via virtual visits.

CONCLUSIONS

Providing specialty care remotely into the homes of individuals with PD is feasible, but a one-time visit did not improve quality of life. Satisfaction with the visits was high among physicians and patients, who were interested in receiving such care in the future.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that for patients with PD, remote specialty care is feasible but does not improve quality of life.

CLINICALTRIALSGOV IDENTIFIER

NCT02144220.

La Enfermedad de Parkinson: Etiología, Tratamientos y Factores Preventivos

La enfermedad de Parkinson (EP) es la patología neurodegenerativa motora con mayor incidencia a nivel mundial. Esta afecta a aproximadamente 2-3% de la población mayor a 60 años de edad y sus causas aún no han sido bien determinadas. Actualmente no existe cura para esta patología; sin embargo, es posible contar con diferentes tratamientos que permiten aliviar algunos de sus síntomas y enlentecer su curso. Estos tratamientos tienen como premisa contrarrestar los efectos ocasionados por la pérdida de la función dopaminérgica de la sustancia nigra (SN) sobre estructuras como el núcleo subtálamico (NST) o globo pálido interno (GPi) ya sea por medio de tratamientos farmacológicos, estimulación cerebral profunda (ECP) o con el implante celular. Existen también investigaciones que están dirigiendo su interés al desarrollo de fármacos con potencial terapéutico, que presenten alta especificidad a receptores colinérgicos de nicotina (nAChRs) y antagonistas de receptores de adenosina, específicamente del subtipo A2A. Estos últimos, juegan un papel importante en el control de liberación dopaminérgica y en los procesos de neuroprotección. En esta revisión se pretende ofrecer una panorámica actual sobre algunos de los factores de riesgo asociados a EP, algunos de los tratamientos actuales más utilizados y acerca del rol de sustancias potencialmente útiles en la prevención de esta enfermedad.

Towards reinforcing telemedicine adoption amongst clinicians in Nigeria

Telemedicine systems have been considered as a necessary measure to alleviate the shortfall in skilled medical specialists in developing countries. However, the obvious challenge is whether clinicians are willing to use this technological innovation, which has aided medical practice globally. One factor which has received little academic attention is the provision of suitable encouragement for clinicians to adopt telemedicine, in the form of rewards, motivation or incentives. A further consideration for telemedicine usage in developing countries, especially sub-Saharan Africa and Nigeria in particular, are to the severe shortage of available practising clinicians. The researchers therefore explore the need to positively reinforce the adoption of telemedicine amongst clinicians in Nigeria, and also offer a rationale for this using the UTAUT model. Data were collected using a structured paper-based questionnaire, with 252 physicians and nurses from six government hospitals in Ondo state, Nigeria. The study applied SmartPLS 2.0 for analysis to determine the relationship between six variables. Demographic moderating variables, age, gender and profession, were included. The results indicate that performance expectancy (p<0.05), effort expectancy (p<0.05), facilitating condition (p<0.01) and reinforcement factor (p<0.001) have significant effects on clinicians' behavioural intention to use telemedicine systems, as predicted using the extended UTAUT model. Our results showed that the use of telemedicine by clinicians in the Nigerian context is perceived as a dual responsibility which requires suitable reinforcement. In addition, performance expectancy, effort expectancy, facilitating condition and reinforcement determinants are influential factors in the use of telemedicine services for remote-patient clinical diagnosis and management by the Nigerian clinicians.

The role and structure of the multidisciplinary team in the management of advanced Parkinson's disease with a focus on the use of levodopa-carbidopa intestinal gel

A multidisciplinary team (MDT) approach is increasingly recommended in Parkinson’s disease (PD) treatment guidelines, but no standard of care exists for such an approach, and the guidelines do not provide clarification on how it should be implemented. This paper reviews evidence of MDT interventions in people with PD and provides expert clinical perspectives for an MDT approach, with a focus on advanced PD and levodopa–carbidopa intestinal gel (carbidopa–levodopa enteral suspension in the USA). The key recommendations are to enable the best possible treatment of people with PD locally by facilitating a close structured collaboration of different health care professionals working in a fixed network structure; to refer people with PD to established MDT centers in a timely manner; to establish regular meetings for the MDT enabling interdisciplinary exchange and learning; to optimize individual treatment and carefully evaluate available treatment options; to ensure treatment decisions are agreed jointly between people with PD, their caregivers, family, and health care professional; and to include specialists outside of neurology from adjuvant medical departments as necessary when implementing advanced therapies.

Models of Care Delivery for Patients With Parkinson Disease Living in Rural Areas

The elderly who suffer from chronic conditions have an increasingly difficult time accessing health care in rural areas compared with their healthy counterparts who seek and utilize less specialty care. Parkinson disease affects approximately 0.3% to 5% of the elderly population. However, a large portion of that population has difficulty accessing health care. The purpose of this study was to obtain an understanding of the access to care issues for patients with Parkinson disease and review solutions to aid their provision of care. A review of the literature found several models of care available to improve access to care issues for patients with Parkinson disease.

Remotely Assessing Symptoms of Parkinson's Disease Using Videoconferencing: A Feasibility Study

Purpose. To evaluate the feasibility of assessing a person's symptoms of Parkinson's disease (PD) in their home using the videoconferencing technology they already possess, without a home visit. Method. Eleven participants with PD completed the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) face-to-face and then via videoconferencing within a two-week period. Participants used free software and the computers and webcams available at their home to complete the videoconference assessment with a clinical rater scoring remotely. Clinical raters and participants provided feedback on the experience. Results. Excluding rigidity and postural stability, between zero and seven items could not be completed in the assessment of each participant (median 2.0, IQR 1.0-4.0). Between face-to-face and videoconference assessments, the median difference in scores was 3.0 (IQR 1.5-9.0). Content analysis of feedback identified the clinical raters' reasons why some scoring could not be completed and the participants' hope for future clinical application. Conclusions. In using free everyday technology available in participants' homes, MDS-UPDRS ratings could be obtained without an initial home visit; however some items were unable to be scored for some participants. Use of a protocol or technological advances are likely to reduce missing items.

Parkinson Patients' Initial Trust in Avatars: Theory and Evidence

Parkinson's disease (PD) is a neurodegenerative disease that affects the motor system and cognitive and behavioral functions. Due to these impairments, PD patients also have problems in using the computer. However, using computers and the Internet could help these patients to overcome social isolation and enhance information search. Specifically, avatars (defined as virtual representations of humans) are increasingly used in online environments to enhance human-computer interaction by simulating face-to-face interaction. Our laboratory experiment investigated how PD patients behave in a trust game played with human and avatar counterparts, and we compared this behavior to the behavior of age, income, education and gender matched healthy controls. The results of our study show that PD patients trust avatar faces significantly more than human faces. Moreover, there was no significant difference between initial trust of PD patients and healthy controls in avatar faces, while PD patients trusted human faces significantly less than healthy controls. Our data suggests that PD patients' interaction with avatars may constitute an effective way of communication in situations in which trust is required (e.g., a physician recommends intake of medication). We discuss the implications of these results for several areas of human-computer interaction and neurological research.

The study on a telemedicine interaction mode for Deep Brain Stimulation postoperative follow-up

Since the development of information technology, telemedicine has been increasingly important in various medical activities. However, telemedicine application for Deep Brain Stimulation (DBS) has not been sufficiently perceived by the public. In this study, we first made a primary exploration to identify the DBS tele-health requirements. According to our questionnaires, 31 participants (22 patients, 9 neurosurgeons) reported an urgent remote adjustment demand. Tele-program combined with video communication were a preferred communication pattern. Based on the requirements discovery, this paper proposed an appropriate interaction mode for DBS remote follow-up. System details were illustrated. Four clinical cases were done in China to test the functionality of the remote monitoring system. The results shows the interaction mode is feasible and efficient for DBS postoperative follow-up.