Telemedicine in Movement Disorders: Leçons du COVID-19

Telemedicine during the COVID-19 epidemic improves outcomes in children with tuberous sclerosis complex: A 1206 visits retrospective cohort study

AIMS

To evaluate the benefits of telemedicine in children with tuberous sclerosis complex during the COVID-19 pandemic.

METHODS

A retrospective cohort study was conducted, comparing telemedicine and in-person visits within the timeframe spanning from June 1, 2021, to June 1, 2022. Disparities in demographics, emergency visits, hospitalizations, adverse effects (AEs) associated with sirolimus, and the incidence of drug-refractory epilepsy (DRE) between telehealth and in-person care were assessed. Additionally, distinctions between audio and video telehealth, as well as varying frequencies of telehealth encounters, were investigated and reported as odds ratios (ORs).

RESULTS

A total of 378 patients with 1206 visits were included, of which 137 were telemedicine patients and 241 were in-person patients. The median age was 5.0 years (IQR 2.8-10.0 years). There were 197 males (52.12%), 691 in-person visits (57.30%), and 515 telemedicine visits (42.70%). Children under 12 years old, those farther away from the center, mothers with more than 12 years of education, and children treated with sirolimus were more likely to visit via telemedicine. Telehealth was associated with significantly fewer emergency visits, hospitalizations, AEs of sirolimus, and DRE. With 10 or more visits, the incidence of emergency visits, hospitalization, and DRE was significantly reduced.

CONCLUSION

Telemedicine visits are almost as close in number as in-person visits. Younger patients, patients in remote areas, and mothers with higher education levels are more willing to complete telemedicine visits. Telemedicine visits were associated with a significantly lower number of emergency visits, hospitalizations, and AEs of sirolimus. Patients with more than 10 visits per year seemed to have better clinical outcomes.

A Scoping Review of Changes to Patient-Doctor Communication During COVID-19

Effective communication between patients and doctors is fundamental to high-quality healthcare, patient safety, and overall satisfaction. However, the onset of COVID-19 has prompted significant shifts in communication from in-room and face-to-face interactions to virtual consults. The impact of this pandemic-related change on patient-doctor communication goals, processes, attributes, and environment remains unclear. We undertook a scoping review involving the systematic search of seven academic databases for relevant articles published up to and including June 2021. In total, 47 articles were identified that met the inclusion criteria. We applied the patient-doctor communication framework to guide our deductive thematic analysis of articles included, sorting results from reported studies and position papers into themes and sub-themes. The theme of communication goals highlighted sub-themes related to patient safety, convenience, affordability, and satisfaction; preparation included sub-themes on technology interventions, workforce training, and digital literacy; participant attributes included compassion for doctors and rebuilding trust among patients; and communication process included issues related to telemedicine or video conferencing, challenges with diminished patient privacy, and distractions in the patient's home setting. Finally, the environment theme included insights into doctors' workload, isolation, and anxiety and how changes requiring increases in virtual consults iteratively altered confidence in care provision and communication with patients. Results of the scoping review provide important insights for strengthening virtual patient-doctor interactions, including target areas for training and professional development during and beyond the current pandemic.

Feasibility of regional center telehealth visits utilizing a rural research network in people with Parkinson's disease

Background

Impaired motor and cognitive function can make travel cumbersome for People with Parkinson's disease (PwPD). Over 50% of PwPD cared for at the University of Arkansas for Medical Sciences (UAMS) Movement Disorders Clinic reside over 30 miles from Little Rock. Improving access to clinical care for PwPD is needed.

Objective

To explore the feasibility of remote clinic-to-clinic telehealth research visits for evaluation of multi-modal function in PwPD.

Methods

PwPD residing within 30 miles of a UAMS Regional health center were enrolled and clinic-to-clinic telehealth visits were performed. Motor and non-motor disease assessments were administered and quantified. Results were compared to participants who performed at-home telehealth visits using the same protocols during the height of the COVID pandemic.

Results

Compared to the at-home telehealth visit group (n = 50), the participants from regional centers (n = 13) had similar age and disease duration, but greater disease severity with higher total Unified Parkinson's disease rating scale scores (Z = -2.218, p = 0.027) and lower Montreal Cognitive Assessment scores (Z = -3.350, p < 0.001). Regional center participants had lower incomes (Pearson's chi = 21.3, p < 0.001), higher costs to attend visits (Pearson's chi = 16.1, p = 0.003), and lived in more socioeconomically disadvantaged neighborhoods (Z = -3.120, p = 0.002). Prior research participation was lower in the regional center group (Pearson's chi = 4.5, p = 0.034) but both groups indicated interest in future research participation.

Conclusions

Regional center research visits in PwPD in medically underserved areas are feasible and could help improve access to care and research participation in these traditionally underrepresented populations.

Effect of Levodopa on Heat Hypersensitivity and Complex Motor Parkinsonism

OBJECTIVES

The aim of the study is to report a case with heat intolerance, complex motor fluctuations, and parkinsonism.

MATERIALS AND METHODS

A male with onset of heat intolerance at the age of 46 years developed left upper limb tremor at the age of 58 years. He was diagnosed with Parkinson disease at the age of 62 years and presented to Movement Disorders Clinic Saskatchewan at the age of 65 years. He reported motor response fluctuations, including WO and dyskinesias. There was no history of dizziness on standing, bladder, or sexual dysfunction. We recorded an asymptomatic drop of orthostatic blood pressure. He reported loss of smell sensation for 5 years and REM behavior disorder characterized by talking in his sleep. He was assessed at the age of 65 years over the course of a day with 4 video recordings of his evolving findings and symptoms with his informed consent.

RESULTS

Initial assessment after levodopa was withheld more than 14 hours revealed him to be 'off' with severe dystonic neck flexion and with bradykinesia and rigidity in the limbs. He was anhidrotic, felt hot, and needed a wet towel over his neck. Over the course of 4 hours, he turns "on" with improvement in heat intolerance, neck hypertonicity, and parkinsonian findings and develops evolving dyskinetic movements before turning "off" again. His overall clinical picture was most consistent with multiple system atrophy.

CONCLUSIONS

Heat intolerance can precede onset of motor symptoms of parkinsonism by several years and supports a diagnosis of multiple system atrophy. To our knowledge, this is the first documented case of improvement in heat intolerance with levodopa.

Dancing for Parkinson's Disease Online: Clinical Trial Process Evaluation

Background: Dancing is an engaging physical activity for people living with Parkinson's disease (PD). We conducted a process evaluation for a PD trial on online dancing. Methods: "ParkinDANCE Online" was co-produced by people with PD, healthcare professionals, dance instructors, and a PD organisation. The evaluation mapped the following inputs: (i) stakeholder steering group to oversee program design, processes, and outcomes; (ii) co-design of online classes, based on a research evidence synthesis, expert advice, and stakeholder recommendations; (iii) trial fidelity. The key activities were (i) the co-design of classes and instruction manuals, (ii) the education of dance teachers, (iii) fidelity checking, (iv) online surveys, (v) and post-trial focus groups and interviews with participants. The outputs pertained to: (i) recruitment, (ii) retention, (iii) adverse events, (iv) fidelity, (v) protocol variations, and (vi) participant feedback. Results: Twelve people with PD, four dance instructors and two physiotherapists, participated in a 6-week online dance program. There was no attrition, nor were there any adverse events. Program fidelity was strong with few protocol variations. Classes were delivered as planned, with 100% attendance. Dancers valued skills mastery. Dance teachers found digital delivery to be engaging and practical. The safety of online testing was facilitated by careful screening and a home safety checklist. Conclusions: It is feasible to deliver online dancing to people with early PD.

Feasibility of telemedicine research visits in people with Parkinson's disease residing in medically underserved areas

Introduction

Gait, balance, and cognitive impairment make travel cumbersome for People with Parkinson's disease (PwPD). About 75% of PwPD cared for at the University of Arkansas for Medical Sciences' Movement Disorders Clinic reside in medically underserved areas (MUAs). Validated remote evaluations could help improve their access to care. Our goal was to explore the feasibility of telemedicine research visits for the evaluation of multi-modal function in PwPD in a rural state.

Methods

In-home telemedicine research visits were performed in PwPD. Motor and non-motor disease features were evaluated and quantified by trained personnel, digital survey instruments for self-assessments, digital voice recordings, and scanned and digitized Archimedes spiral drawings. Participant's MUA residence was determined after evaluations were completed.

Results

Twenty of the fifty PwPD enrolled resided in MUAs. The groups were well matched for disease duration, modified motor UPDRS, and Montreal Cognitive assessment scores but MUA participants were younger. Ninety-two percent were satisfied with their visit, and 61% were more likely to participate in future telemedicine research. MUA participants traveled longer distances, with higher travel costs, lower income, and education level. While 50% of MUA participants reported self-reliance for in-person visits, 85% reported self-reliance for the telemedicine visit. We rated audio-video quality highly in approximately 60% of visits in both groups. There was good correlation with prior in-person research assessments in a subset of participants.

Conclusions

In-home research visits for PwPD in MUAs are feasible and could help improve access to care and research participation in these traditionally underrepresented populations.

Remote Evaluation of Parkinson's Disease Using a Conventional Webcam and Artificial Intelligence

Objective: This study aimed to prove the concept of a new optical video-based system to measure Parkinson's disease (PD) remotely using an accessible standard webcam.

Methods: We consecutively enrolled a cohort of 42 patients with PD and healthy subjects (HSs). The participants were recorded performing MDS-UPDRS III bradykinesia upper limb tasks with a computer webcam. The video frames were processed using the artificial intelligence algorithms tracking the movements of the hands. The video extracted features were correlated with clinical rating using the Movement Disorder Society revision of the Unified Parkinson's Disease Rating Scale and inertial measurement units (IMUs). The developed classifiers were validated on an independent dataset.

Results: We found significant differences in the motor performance of the patients with PD and HSs in all the bradykinesia upper limb motor tasks. The best performing classifiers were unilateral finger tapping and hand movement speed. The model correlated both with the IMUs for quantitative assessment of motor function and the clinical scales, hence demonstrating concurrent validity with the existing methods.

Conclusions: We present here the proof-of-concept of a novel webcam-based technology to remotely detect the parkinsonian features using artificial intelligence. This method has preliminarily achieved a very high diagnostic accuracy and could be easily expanded to other disease manifestations to support PD management.

Clinical perception and management of Parkinson's disease during the COVID-19 pandemic: A Canadian experience

Background

The COVID-19 pandemic has necessitated the social isolation of the population and the rapid implementation of remote care for patients with neurodegenerative diseases. The objective of this study was to explore the perceived impact of confinement in patients with Parkinson's disease and document the effects of gender and living environment.

Methods

We recruited two cohorts from the Canadian provinces of Québec and Alberta, which differed in the dynamics of COVID-19 spreading at the time of the study, and administered a questionnaire on the perceived effects of confinement on daily living and disease management.

Results

The data reveals that approximately half of the patients experienced a change in one or more clinical symptoms, with differences observed between gender (e.g. day-to-day changes in slowness in men, aggravated headaches in women) and geographic location (e.g. increased depression in Alberta but reduced sleep quality in Québec). Furthermore, participants identifying as women or living in Alberta implemented more frequently home or online exercise. Lastly, high levels of satisfaction with phone or video consultations did not translate into a sustained interest to pursue this mode of healthcare.

Conclusions

This study suggests that COVID-19-related confinement affected Parkinson's disease manifestation and management. Patients also reported varying levels of interest to continue remote care. A number of differences reported in our study were seemingly related to gender and living environment.

Botulinum Toxin Services for Neurorehabiliation: Recommendations for Challenges and Opportunities during the COVID-19 Pandemic

The COVID-19 pandemic severely impacted the function of medical facilities and rehabilitation services worldwide, including toxin services delivering Botulinum toxin treatments for neuromuscular conditions such as spasticity, dystonia, and sialorrhea. The aim of this paper is to understand how toxin services have dealt with the situation and what strategies have been adopted to continue services. The recommendations are based on a virtual round table held with toxin services experts from different European countries who shared their experiences and discussed the best practices. The challenges for toxin services were reviewed based on the experts' experiences and on relevant literature from 2020 and 2021. A set of recommendations and best practices were compiled, focusing firstly on guidance for clinical practice, including assessing patients' health and risk status and the urgency of their treatment. Secondly, it was discussed how patients on botulinum toxin therapy can be cared for and supported during the pandemic, and how modern technology and tele-medicine platforms can be generally used to optimize effectiveness and safety of toxin treatments. The technological advances prompted by the COVID-19 crisis can result in better and more modern patient care in the future.

Teleneurology in Parkinson's disease: A step-by-step video guide

BACKGROUND

The COVID-19 pandemic forced the implementation of social distancing and circulation restrictions. This affected all aspects of society including health care. In the field of chronic neurological disorders such as Parkinson's disease (PD), teleneurology is employed in scenarios where face-to-face interactions are not possible. A growing number of clinicians and institutions are turning to teleneurology in order to providing medical care.

AIMS OF THE ARTICLE

In this manuscript, we present a practical, 'how we do it in real life', example of a teleneurology appointment with a person with PD (PwP).

METHODS

We elaborated a step-by-step approach of the main aspects of a consultation with a PwP and provide video illustration.

RESULTS

The key aspects of a teleneurology appointment were separated into: (1) In the office, before the appointment; (2) History taking; (3) Examination; and (4) Finishing up.

CONCLUSIONS

We discuss the strengths and weaknesses of this approach and provide our experience in overcoming commonly encountered difficulties.

The state of telemedicine for persons with Parkinson's disease

PURPOSE OF REVIEW

The COVID-pandemic has facilitated the implementation of telemedicine in both clinical practice and research. We highlight recent developments in three promising areas of telemedicine: teleconsultation, telemonitoring, and teletreatment. We illustrate this using Parkinson's disease as a model for other chronic neurological disorders.

RECENT FINDINGS

Teleconsultations can reliably administer parts of the neurological examination remotely, but are typically not useful for establishing a reliable diagnosis. For follow-ups, teleconsultations can provide enhanced comfort and convenience to patients, and provide opportunities for blended and proactive care models. Barriers include technological challenges, limited clinician confidence, and a suboptimal clinician-patient relationship. Telemonitoring using wearable sensors and smartphone-based apps can support clinical decision-making, but we lack large-scale randomized controlled trials to prove effectiveness on clinical outcomes. Increasingly many trials are now incorporating telemonitoring as an exploratory outcome, but more work remains needed to demonstrate its clinical meaningfulness. Finding a balance between benefits and burdens for individual patients remains vital. Recent work emphasised the promise of various teletreatment solutions, such as remotely adjustable deep brain stimulation parameters, virtual reality enhanced exercise programs, and telephone-based cognitive behavioural therapy. Personal contact remains essential to ascertain adherence to teletreatment.

SUMMARY

The availability of different telemedicine tools for remote consultation, monitoring, and treatment is increasing. Future research should establish whether telemedicine improves outcomes in routine clinical care, and further underpin its merits both as intervention and outcome in research settings.

Accurate Monitoring of Parkinson's Disease Symptoms With a Wearable Device During COVID-19 Pandemic

BACKGROUND

Accurate assessment of symptoms in Parkinson's disease (PD) is essential for optimal treatment decisions. During the past few years, different monitoring modalities have started to be used in the everyday clinical practice, mainly for the evaluation of motor symptoms. However, monitoring technologies for PD have not yet gained wide acceptance among physicians, patients, and caregivers. The COVID-19 pandemic disrupted the patients' access to healthcare, bringing to the forefront the need for wearable sensors, which provide effective remote symptoms' evaluation and follow-up.

CASE REPORT

We report two cases with PD, whose symptoms were monitored with a new wearable CE-marked system (PDMonitor^®), enabling appropriate treatment modifications.

CONCLUSION

Objective assessment of the patient's motor symptoms in his daily home environment is essential for an accurate monitoring in PD and enhances treatment decisions.

Telemedicine in Neurology: A Scoping Review of Key Outcomes in Movement Disorders

Background: Telemedicine for neurological care has been researched and practiced in various ways over the past three decades, but the recent COVID-19 pandemic has rapidly expanded its use and highlighted the need for a synthesis of the existing literature. We aimed to review the methodology and outcomes of previous studies that have evaluated the use of telemedicine in movement disorders. Methods: This scoping review was performed by searching PubMed, Ovid MEDLINE, and CINAHL databases from 1946 to November 2020. Studies that assessed the application of telemedicine for delivering care to patients with a movement disorder were included. We reported the aims and employed methodologies and categorized the outcomes from each study. Results: The search retrieved 228 articles, and 41 studies met the criteria for inclusion in the review. The majority of telemedicine studies were case series or randomized controlled pilot trials, investigating feasibility and acceptability in Parkinson's disease. Even with heterogeneity among outcome measures, they can be categorized into themes, such as feasibility, satisfaction, and efficacy. Conclusions: Telemedicine use has grown rapidly, due to the demands of providing care during a global pandemic. This application of telemedicine has been considered a promising way to expand care in Neurology, although research evaluating the dissemination of its use is dilatory. This review highlights the number of studies that have found telemedicine to be an acceptable and feasible way to deliver care for movement disorders. Further research is needed to expand on harmonization of outcomes, reach, adoption, and long-term use of telemedicine.

Parkinson's Disease and the COVID-19 Pandemic

Studies focusing on the relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), coronavirus disease 2019 (COVID-19), and Parkinson’s disease (PD) have provided conflicting results. We review the literature to investigate: 1) Are PD patients at higher risk for contracting COVID-19 and are there specific contributing factors to that risk? 2) How does COVID-19 affect PD symptoms? 3) How does COVID-19 present in PD patients? 4) What are the outcomes in PD patients who contract COVID-19? 5) What is the impact of COVID-19 on PD care? 6) Does COVID-19 increase the risk of developing PD? A literature search was performed from 1979 to 2020 using the terms: ‘Parkinson’s disease’ and ‘parkinsonism’ combined with: ‘COVID-19’; ‘SARS-CoV-2’ and ‘coronavirus’. It does not appear that PD is a specific risk factor for COVID-19. There is evidence for direct/indirect effects of SARS-CoV-2 on motor/non-motor symptoms of PD. Although many PD patients present with typical COVID-19 symptoms, some present atypically with isolated worsening of parkinsonian symptoms, requiring increased anti-PD therapy and having worse outcomes. Mortality data on PD patients with COVID-19 is inconclusive (ranging from 5.2%to 100%). Patients with advanced PD appear to be particularly vulnerable. Single cases of acute hypokinetic-rigid syndrome have been described but no other convincing data has been reported. The rapidity with which COVID-19 has swept across the globe has favored the proliferation of studies which lack scientific rigor and the PD literature has not been immune. A coordinated effort is required to assimilate data and answer these questions in larger PD cohorts.

Uptake of telehealth in Parkinson's disease clinical care and research during the COVID-19 pandemic

INTRODUCTION

Traditionally, medical care and research in Parkinson's disease (PD) have been conducted with in-person encounters. The recent COVID-19 pandemic has profoundly impacted the delivery of in-person clinical care and clinical research. We conducted an online survey of active clinician members of the Parkinson Study Group (PSG) to evaluate the adoption of various non-face-to-face methods in clinical practice and research in PD during the COVID-19 pandemic.

METHODS

We conducted a survey using the open-access online SurveyMonkey tool (http://www.surveymonkey.com). The survey had 27 items and was designed to elucidate clinical/research care before and during the COVID-19 pandemic. The survey was sent to 414 active PSG members with weekly reminders and it remained accessible for 30 days from May 2020.

RESULTS

We received 142 responses, of which 133 (93.7%) provided demographic data. The clinical use of virtual visits via synchronous video conferencing increased from 39.5% pre-COVID-19 to 94.6% during the COVID-19 pandemic. Lack of access for patients (68.2%) and patient resistance (51.4%) were the top barriers for its use. Approximately 70% respondents stated that 75-100% of their research activities were suspended during the COVID-19 pandemic. Many sites had to fill out protocol deviations (38.2%), protocol exceptions (25.5%) or change their research profile due to layoffs (16.8%). The overall use of video conferencing increased from 30.3% to 64.1%.

CONCLUSION

The current results suggest a need for flexibility in conducting office visits and clinical trials in PD patients. Technology has the potential to enhance patient care and convenience, when in-person visits can be challenging.

Telehealth in Neurodegenerative Diseases: Opportunities and Challenges for Patients and Physicians

Telehealth, by definition, is distributing health-related services while using electronic technologies. This narrative Review describes the technological health services (telemedicine and telemonitoring) for delivering care in neurodegenerative diseases, Alzheimer's disease, Parkinson's Disease, and amyotrophic lateral Sclerosis, among others. This paper aims to illustrate this approach's primary experience and application, highlighting the strengths and weaknesses, with the goal of understanding which could be the most useful application for each one, in order to facilitate telehealth improvement and use in standard clinical practice. We also described the potential role of the COVID-19 pandemic to speed up this service's use, avoiding a sudden interruption of medical care.

Parkinson's disease patients' needs during the COVID-19 pandemic in a red zone: A framework analysis of open-ended survey questions

Background and purpose

During the first phase of the COVID‐19 pandemic, a lockdown was imposed in Italy. The aim of this study was to investigate the perceptions, feelings and unmet needs of Parkinson's disease (PD) patients who experienced the 2‐month lockdown in a “red zone” in the northern part of Italy during the COVID‐19 outbreak.

Methods

The study had a descriptive design that used a cross‐sectional online survey which included open‐ended questions to elicit responses on the participant's feelings concerning their risk of contracting coronavirus, how their physical activity had changed, and their personal needs, dictated by their condition, which were not met in this pandemic period as compared to previous periods. Demographic data were analysed using descriptive frequencies, while the open‐ended questions were analysed using thematic framework analysis.

Results

The study included 103 participants (63 men/40 women [61.17 vs. 38.83%]). Framework analysis led to the identification of four main themes: (i) fearing the risk of contracting coronavirus; (ii) reduction of physical activity; (iii) perception of the risk of not being able to access outpatient clinics or support services; and (iv) negative experiences of the important reduction in socialization. The perceptions of unmet needs appeared to be greater than the actual experience, particularly for the reduction in physical activity and the interruption of contacts with the neurologist and other specialists.

Conclusions

This study highlights how perceptions and actual experience shape the meaning of living with PD during the pandemic. Worth noting is the divergence between perceptions and real impact in some aspects of the COVID‐19 outbreak.

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.