Telemedicine for Hyperkinetic Movement Disorders

The Growing Role of Telerehabilitation and Teleassessment in the Management of Movement Disorders in Rare Neurological Diseases: A Scoping Review

Background: People with rare neurological diseases (RNDs) often experience symptoms related to movement disorders, requiring a multidisciplinary approach, including rehabilitation. Telemedicine applied to rehabilitation and symptom monitoring may be suitable to ensure treatment consistency and personalized intervention. The objective of this scoping review aimed to emphasize the potential role of telerehabilitation and teleassessment in managing movement disorders within RNDs. By providing a systematic overview of the available literature, we sought to highlight potential interventions, outcomes, and critical issues. Methods: A literature search was conducted on PubMed, Google Scholar, IEEE, and Scopus up to March 2024. Two inclusion criteria were followed: (1) papers focusing on telerehabilitation and teleassessment and (2) papers dealing with movement disorders in RNDs. Results: Eighteen papers fulfilled the inclusion criteria. The main interventions were home-based software and training programs, exergames, wearable sensors, smartphone applications, virtual reality and digital music players for telerehabilitation; wearable sensors, mobile applications, and patient home video for teleassessment. Key findings revealed positive outcomes in gait, balance, limb disability, and in remote monitoring. Limitations include small sample sizes, short intervention durations, and the lack of standardized protocols. Conclusion: This review highlighted the potential of telerehabilitation and teleassessment in addressing movement disorders within RNDs. Data indicate that these modalities may play a major role in supporting conventional programs. Addressing limitations through multicenter studies, longer-term follow-ups, and standardized protocols is essential. These measures are essential for improving remote rehabilitation and assessment, contributing to an improved quality of life for people with RNDs.

Clinical correlates of movement disorders in adult Niemann-Pick type C patients measured via a Personal KinetiGraph

Background

Niemann-Pick type C (NPC) is an autosomal recessive progressive neurodegenerative disorder caused by mutations in the NPC1 or NPC2 genes. Patients with this disorder have variable phenotypic presentations that often include neuropsychiatric manifestations, cognitive decline, and movement disorders. There is considerable interpatient variation in movement disorders, with limited quantitative measurements describing the movements observed. Objective measurements using wearable sensors provide clinically applicable monitoring of patients with Parkinson’s disease, and hence may be utilized in patients with NPC.

Objective

To explore the relationship between objective measurements of movement obtained via the use of the Personal KinetiGraph (PKG) with the clinical information obtained via questionnaires and clinical rating tools of patients with Niemann-Pick type C.

Methods

Twelve patients with Niemann-Pick type C were recruited who wore the PKG for 6 days during regular activities. A 6-day output was provided by the manufacturer, which provided bradykinesia (BK) and dyskinesia (DK) scores. BK and DK scores were further divided into their interquartile ranges. A fluctuation score (FDS), percentage time immobile (PTI), and percent time with tremors (PTT) were also provided. Clinical assessments included Abnormal Involuntary Movement Scale (AIMS), Epworth Sleepiness Score (ESS), Falls, Neuropsychiatric Unit Assessment Tool (NUCOG), Parkinson’s disease questionnaire (PDQ), and modified Unified Parkinson’s Disease Rating Scale (UPDRS) which were performed over telehealth within 2 weeks of PKG use. Pearson’s correlation analyses were utilized to explore the relationship between DK and BK quartiles and clinical measures.

Results

We found bradykinesia to be a feature among this cohort of patients, with a median BKS of 22.0 (7.4). Additionally, PTI scores were elevated at 4.9 (8.2) indicating elevated daytime sleepiness. Significant correlations were demonstrated between BK25 and Falls (r =  − 0.74, 95% CI = [− 0.95, − 0.08]), BK50 and Falls (r =  − 0.79, 95% CI = [− 0.96, − 0.19]), and BK75 and Falls (r =  − 0.76, 95% CI = [− 0.95, − 0.11]). FDS correlated with PDQ (r =  − 0.7, 95% CI = [− 0.92, − 0.18]), UPDRS IV (r =  − 0.65, 95% CI = [− 0.90, − 0.09]), UPDRS (r =  − 0.64, 95% CI = [− 0.9, − 0.06]), and AIMS (r =  − 0.96, 95% CI = [− 0.99, − 0.49]). DK25 in comparison with NUCOG-A (r = 0.72, 95% CI = [0.17, 0.93]) and DK75 in comparison with NUCOG (r = 0.64, 95% CI = [0.02, 0.91]) and NUCOG-A (r = 0.63, 95% CI = [0.01, 0.90]) demonstrated significant correlations. Additionally, duration of illness in comparison with PTI (r = 0.72, 95% CI = [0.22, 0.92]) demonstrated significance.

Conclusions

Utilization of PKG measures demonstrated that bradykinesia is under recognized among NPC patients, and the bradykinetic patients were less likely to report concerns regarding falls. Additionally, the FDS rather than the DKS is sensitive to the abnormal involuntary movements of NPC—reflecting a differing neurobiology of this chorea compared to levodopa-induced dyskinesias. Furthermore, dyskinetic individuals performed better in cognitive assessments of attention which may indicate an earlier timepoint within disease progression.

A questionnaire-based survey of acceptability and satisfaction of virtual neurology clinic during COVID-19 lockdown: a preliminary study

Introduction

Telemedicine during this pandemic acts as a lifeline for many non-COVID patients especially with chronic neurological diseases. The aim of present study was to evaluate cost effectiveness and level of satisfaction amongst patients from teleneurology outpatient department (OPD).

Methods

An online cross-sectional survey, having questions both in Hindi and English was conducted via telemedicine facility at Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Demographic variables, illness details, travel distance and time taken, travel expenditure, level of satisfaction and preferred choice among tele OPD versus in-person OPD once pandemic ends were recorded.

Results

Total 1388 patients filled the online COVID-19 teleneurology survey google form. Mean age was 39.21 ± 16.72 years. Majority (N = 824, 59%) were males. Six hundred (43%) patients’ educational qualification were ≤ 10th standard. Majority of patients (N = 840, 60.5%) belonged to the rural background. Headache (N = 424, 30.5%) followed by backache (N = 220, 16%), stroke (N = 176, 13%) and seizure (N = 148, 11%) were the common illnesses. Travel time of > 5 hours was saved in 496 (36%) patients and travel expenditure of > Rs100 in 796 (57%) patients. About 96% (N = 1332) felt satisfied with the treatment advice via teleconsultation.

Discussion

Teleneurology facility is not only feasible but also affordable and acceptable in various neurological conditions. The chief reasons being no waiting time, saving of travelling time and travel expenditure with good satisfaction.

Using Telemedicine to Assess and Manage Psychosis in Neurodegenerative Diseases in Long-Term Care

The coronavirus disease 2019 (COVID-19) epidemic has forced a sudden global implementation of telemedicine strategies, including in long-term care (LTC) facilities where many people with dementia and Parkinson disease (PD) reside. Telemedicine offers a unique set of advantages for residents in LTC facilities if effectively supported and implemented, including expanded access to specialists in rural or underserved areas or for people with dementia who cannot travel for off-site visits. Many medical and psychiatric organizations have recently issued new or updated guidelines on the use of telemedicine. On October 22, 2020, a multidisciplinary consensus panel was convened to collate a list of best practices for LTC facilities and specialists when conducting telemedicine with residents with dementia-related psychosis or PD-related psychosis (PDP).

A collaborative effort between specialists, facility administrators, and facility staff is essential for the success of telemedicine in the LTC setting. Telemedicine in LTC facilities comes with increased administrative and technical challenges that fall heavily on the shoulders of the LTC facility administrators and staff. Specialists can ease this burden by maintaining flexibility and ensuring expression of empathy and thanks to the staff who are facilitating the visits. LTC staff can provide specialists with valuable information about their patients to aid in evaluation and diagnosis. Specialists can facilitate this exchange of information by speaking to staff who work closely with the resident about any signs of hallucinations or delusions they may have observed. Educational efforts can increase staff understanding of dementia and PDP and empower them to engage with, and facilitate the resident's treatment plan. Using these strategies to take advantage of the benefits of telemedicine, specialists and LTC staff can together expand and improve care for LTC facility residents with dementia-related psychosis or PDP.

Clinician Perceptions of the Negative Impact of Telehealth Services in the Management of Drug-Induced Movement Disorders and Opportunities for Quality Improvement: A 2021 Internet-Based Survey

PURPOSE

Tardive dyskinesia (TD) is a drug-induced movement disorder (DIMD) seen in patients taking dopamine-receptor blocking agents (DRBAs). Clinicians should regularly monitor patients with or at risk of developing DIMDs; however, telehealth visits during the COVID-19 pandemic presented several significant challenges related to screening and care of these patients. In this observational survey study, respondents compared in-person with video/telephone visits to determine the impact on the evaluation, diagnosis, and monitoring of patients with DIMDs.

METHODS

The online survey was conducted (May 14-June 21, 2021) with qualified clinicians who prescribed a vesicular monoamine transporter 2 inhibitor or benztropine for DIMDs in the past 6 months, spent ≤70% of their professional time in the clinic, and conducted telehealth visits with ≥15% of their patients between December 2020 and January 2021. The questionnaire probed clinicians about their ability to evaluate, diagnose and monitor (hereinafter referred to as manage) patients with DIMDs via telehealth.

RESULTS

Survey respondents included 277 clinicians from psychiatry (n = 168) and neurology (n = 109) practices. Certain signs and symptoms (visual cues) used for diagnosis of DIMDs were not observable through telehealth and evaluation was comparatively more difficult with phone visits than video visits. Patients without caregivers and lower-functioning patients were at higher risk of missed diagnosis of DIMDs and were also difficult to monitor via telehealth. Limited access to computers or telephones and patients living alone were among the top socioeconomic barriers limiting clinicians' ability to diagnose DIMDs. Patients without a regular caregiver were also more difficult for clinicians to evaluate and monitor adequately. Further, most clinicians received no training related to evaluation of DIMDs via telehealth or engaging caregivers as health care partners.

CONCLUSION

Our study highlights specific limitations and challenges and provides considerations to help clinicians better manage DIMDs in the context of telehealth services.

Utility of telemedicine in sub-Saharan Africa during the COVID-19 pandemic. A rapid review

Telemedicine is the use of technology to achieve remote care. This review looks at the utility of telemedicine during the pandemic, period March 2020 to February 2021. Eleven articles met inclusion criteria. There was moderate use of telemedicine in sub‐Sahara Africa during the pandemic, however, there were also some limitations. Benefits of telemedicine include continuing medical service provision, connecting relatives with loved ones in quarantine, education, and awareness of mental health issues, and toxicovigilance and infection control. Challenges to the implementation of telemedicine on the continent were lack of supporting telemedicine framework and policies, digital barriers, and patient and healthcare personnel biases. To address these challenges, this article proposes the development of policy frameworks that fosters telemedicine use by all stakeholders, including medical insurance organizations, the introduction of telemedicine training of medical workers, educational awareness programs for the public, and improvement of digital platforms access and affordability.

Telemedicine Adoption during the COVID-19 Pandemic: Gaps and Inequalities

BACKGROUND

The telemedicine industry has been experiencing fast growth in recent years. The outbreak of coronavirus disease 2019 (COVID-19) further accelerated the deployment and utilization of telemedicine services. An analysis of the socioeconomic characteristics of telemedicine users to understand potential socioeconomic gaps and disparities is critical for improving the adoption of telemedicine services among patients.

OBJECTIVES

This study aims to measure the correlation of socioeconomic determinants with the use of telemedicine services in Milwaukee metropolitan area.

METHODS

Electronic health record review of patients using telemedicine services compared with those not using telemedicine services within an academic-community health system: patient demographics (e.g., age, gender, race, and ethnicity), insurance status, and socioeconomic determinants obtained through block-level census data in Milwaukee area. The telemedicine users were compared with all other patients using regression analysis. The telemedicine adoption rates were calculated across regional ZIP codes to analyze the geographic patterns of telemedicine adoption.

RESULTS

A total of 104,139 patients used telemedicine services during the study period. Patients who used video visits were younger (median age 48.12), more likely to be White (odds ratio [OR] 1.34; 95% confidence interval [CI], 1.31-1.37), and have private insurance (OR 1.43; CI, 1.41-1.46); patients who used telephone visits were older (median age 57.58), more likely to be Black (OR 1.31; CI 1.28-1.35), and have public insurance (OR 1.30; CI 1.27-1.32). In general, Latino and Asian populations were less likely to use telemedicine; women used more telemedicine services in general than men. In the multiple regression analysis of social determinant factors across 126 ZIP codes, college education (coefficient 1.41, p = 0.01) had a strong correlation to video telemedicine adoption rate.

CONCLUSION

Adoption of telemedicine services was significantly impacted by the social determinant factors of health, such as income, education level, race, and insurance type. The study reveals the potential inequities and disparities in telemedicine adoption.

Satisfaction of Telehealth in Patients With Established Neuromuscular Disorders

Introduction/aims: Determine established neuromuscular disease patients' satisfaction with telehealth during the COVID-19 pandemic. Methods: We received 50 completed Utah telehealth satisfaction surveys from a cohort of 90 from April 2020 to June 2020. Returning neuromuscular disease patients rated seven aspects from 1 (strongly disagree) to 5 (strongly agree): Communication, timeliness of physician, picture quality, sound quality, protection of privacy, the comfort of the physical exam, the ease of healthcare, and whether patients would prefer "in-person" visits despite safety precaution. A favorable response was defined as a response of "Agree" or "Strongly Agree" to the survey questions. An independent t-test, Fisher's or chi-square test were used to compare demographic factors on outcomes for each survey question. Results: The average age was 47.54 ± 20.63, 54% were female, 70% from rural areas, 60% had family present "webside," and 14% had family present remotely. The majority of patients reported "Agree" or "Strongly Agree" to each survey question assessing their telehealth satisfaction, except for whether patients preferred in-person appointments. Demographic factors, including location and clinical diagnosis, did not influence survey responses. Discussion: The vast majority of established neuromuscular disease patients responded favorably to their telehealth experience during the COVID-19 pandemic.

A Self-Reported Clinical Tool Predicts Falls in People with Parkinson's Disease

BACKGROUND

A 3-step clinical prediction tool including falling in the previous year, freezing of gait in the past month and self-selected gait speed <1.1 m/s has shown high accuracy in predicting falls in people with Parkinson's disease (PD). The accuracy of this tool when including only self-report measures is yet to be determined.

OBJECTIVES

To validate the 3-step prediction tool using only self-report measures (3-step self-reported prediction tool), and to externally validate the 3-step clinical prediction tool.

METHODS

The clinical tool was used with 137 individuals with PD. Participants also answered a question about self-reported gait speed, enabling scoring of the self-reported tool, and were followed-up for 6 months. An intraclass correlation coefficient (ICC2,1) was calculated to evaluate test-retest reliability of the 3-step self-reported prediction tool. Multivariate logistic regression models were used to evaluate the performance of both tools and their discriminative ability was determined using the area under the curve (AUC).

RESULTS

Forty-two participants (31%) reported ≥1 fall during follow-up. The 3-step self-reported tool had an ICC2,1 of 0.991 (95% CI 0.971-0.997; P < 0.001) and AUC = 0.68; 95% CI 0.59-0.77, while the 3-step clinical tool had an AUC = 0.69; 95% CI 0.60-0.78.

CONCLUSIONS

The 3-step self-reported prediction tool showed excellent test-retest reliability and was validated with acceptable accuracy in predicting falls in the next 6 months. The 3-step clinical prediction tool was externally validated with similar accuracy. The 3-step self-reported prediction tool may be useful to identify people with PD at risk of falls in e/tele-health settings.

Telemedicine in an Academic Movement Disorders Center during COVID-19

Objective

Telemedicine has rapidly gained momentum in movement disorder neurology during the coronavirus disease (COVID-19) pandemic to preserve clinical care while mitigating the risks of in-person visits. We present data from the rapid implementation of virtual visits in a large, academic, movement disorder practice during the COVID-19 pandemic.

Methods

We describe the strategic shift to virtual visits and retrospectively examine elements that impacted the ability to switch to telemedicine visits using historical prepandemic in-person data as a comparator, including demographics, distance driven, and diagnosis distribution, with an additional focus on patients with deep brain stimulators.

Results

A total of 686 telemedicine visits were performed over a five-week period (60% of those previously scheduled for in-office visits). The average age of participants was 65 years, 45% were female, and 73% were Caucasian. Men were more likely to make the transition (p = 0.02). Telemedicine patients lived farther from the clinic than those seen in person (66.47 km vs. 42.16 km, p < 0.001), age was not associated with making the switch, and patient satisfaction did not change. There was a significant shift in the distribution of movement disorder diagnoses seen by telemedicine compared to prepandemic in-person visits (p < 0.001). Patients with deep brain stimulators were more likely to use telemedicine (11.5% vs. 7%, p < 0.001).

Conclusion

Telemedicine is feasible, viable and relevant in the care of movement disorder patients, although health care disparities appear evident for women and minorities. Patients with deep brain stimulators preferred telemedicine in our study. Further study is warranted to explore these findings.

Telemedicine for Pre-Employment Medical Examinations and Follow-Up Visits on Board Ships: A Narrative Review on the Feasibility

BACKGROUND

Telemedicine has already been applied to various medical specialties for diagnosis, treatment, and follow-up visits for the general population. Telemedicine has also proven effective by providing advice, diagnosis, and treatment to seafarers during emergency medical events onboard ships. However, it has not yet been applied for pre-employment medical examinations and follow-up visits on board ships.

OBJECTIVE

This review aimed to assess the possibility of using telemedicine during periodic visits between one pre-employment medical examination and others on board ships, and to recommend necessary medical examination tests with screening intervals for seafarers.

METHODS

Various databases including PubMed, EMBASE, Scopus, CINAHL, and Cochrane Library were explored using different keywords, titles, and abstracts. Studies published between 1999 and 2019, in English, in peer-reviewed journal articles, and that are conference proceedings were considered. Finally, the studies included in this review were chosen on the basis of the eligibility criteria.

RESULTS

Out of a total of 168 studies, 85 studies were kept for further analysis after removing the duplicates. A further independent screening based on the inclusion and exclusion criteria resulted in the withdrawal of 51 studies that were not further considered for our analysis. Finally, 32 studies were left, which were critically reviewed. Out of 32 accepted studies, 10 studies demonstrated the effectiveness of the electrocardiogram (ECG) in monitoring and managing remote patients with heart failure, early diagnosis, and postoperative screening. In 15 studies, telespirometry was found to be effective in diagnosing and ruling out diseases, detecting lung abnormalities, and managing patients with chronic obstructive pulmonary disease (COPD) and asthma. Seven studies reported that telenephrology was effective, precise, accurate, and usable by non-medical personnel and that it reduced sample analysis times and procedures in laboratories.

CONCLUSION

using new technologies such as high-speed internet, video conferencing, and digital examination, personnel are able to make the necessary tests and perform virtual medical examination on board ships with necessary training.

Potential impact and challenges associated with Parkinson's disease patient care amidst the COVID-19 global pandemic

BACKGROUND

COVID-19 has made itself known to health care providers and families across the world in a matter of months. While primarily a respiratory disorder, it has also been shown to cause neurological symptoms, which can be a concern for Parkinson's disease (PD) patients. Although PD is not as common as other conditions such as cardiovascular diseases, it affects millions of patients around the world whose care has been affected by the global pandemic.

OBJECTIVES

The aim of this review is to provide insight into the direct and indirect associations between COVID-19 and PD patient care.

RESULTS

Potential direct effects of COVID-19 include possible neurodegeneration, concerns of symptom self-management with over-the-counter (OTC) products and ICU challenges that can arise in PD patients. In addition, a subset of PD patients may be at higher risk of severe COVID-19 infection. The indirect effects of the pandemic are associated with the social distancing measures and disruptions in health care systems and PD clinical trials, which may negatively affect PD patients' mental wellbeing and create barriers in controlling their PD symptoms. On a more positive note, telemedical care is quickly emerging as a primary communication tool for virtual patient care. However, further research should be conducted to examine the applicability of telemedicine across the entire PD population, such as those with more severe symptoms living in less developed areas. With all the uncertainty during this time, it is hopeful to hear many promising COVID-19 treatments being researched, one of them being a PD drug therapy, amantadine.

CONCLUSION

Hopefully, we can consider this pandemic an opportunity to strengthen the PD community and learn more about the impact of the SARS-COV-2 virus. This review provides an overview of the interaction between COVID-19 and PD patients and future investigational retrospective studies are suggested to validate the observations.

Teleneurology during the COVID-19 pandemic: A step forward in modernizing medical care

BACKGROUND

The COVID-19 pandemic mandated rapid transition from face-to-face encounters to teleneurology visits. While teleneurology is regularly used in acute stroke care, its application in other branches of neurology was limited. Here we review how the recent pandemic has created a paradigm shift in caring for patients with chronic neurological disorders and how academic institutions have responded to the present need.

METHOD

Literature review was performed to examine the recent changes in health policies. Number of outpatient visits and televisits in the Department of Neurology was reviewed from Yale University School of Medicine and Johns Hopkins School of Medicine to examine the road to transition to televisit.

RESULTS

The federal government and the insurance providers extended their supports during the COVID-19 pandemic. Several rules and regulations regarding teleneurology were revised and relaxed to address the current need. New technologies for video conferencing were incorporated. The transition to televisits went smoothly in both the institutions and number of face-to-face encounters decreased dramatically along with a rapid rise in televisits within 2 weeks of the declaration of national emergency.

CONCLUSION AND RELEVANCE

The need for "social distancing" during the COVID-19 pandemic has created a major surge in the number of teleneurology visits, which will probably continue for the next few months. It may have initiated a more permanent transition to virtual technology incorporated medical care.

Management of Advanced Therapies in Parkinson's Disease Patients in Times of Humanitarian Crisis: The COVID-19 Experience

Background

Although the COVID-19 pandemic is affecting a relatively small proportion of the global population, its effects have already reached everyone. The pandemic has the potential to differentially disadvantage chronically ill patients, including those with Parkinson's disease (PD). The first health care reaction has been to limit access to clinics and neurology wards to preserve fragile patients with PD from being infected. In some regions, the shortage of medical staff has also forced movement disorders neurologists to provide care for patients with COVID-19.

Objective

To share the experience of various movement disorder neurologists operating in different world regions and provide a common approach to patients with PD, with a focus on those already on advanced therapies, which may serve as guidance in the current pandemic and for emergency situations that we may face in the future.

Conclusion

Most of us were unprepared to deal with this condition given that in many health care systems, telemedicine has been only marginally available or only limited to email or telephone contacts. In addition, to ensure sufficient access to intensive care unit beds, most elective procedures (including deep brain stimulation or the initiation of infusion therapies) have been postponed. We all hope there will soon be a time when we will return to more regular hospital schedules. However, we should consider this crisis as an opportunity to change our approach and encourage our hospitals and health care systems to facilitate the remote management of chronic neurological patients, including those with advanced PD.

Gilles de la Tourette Syndrome: advice in the times of COVID-19

The novel coronavirus disease (COVID-19) was identified as the cause of an outbreak of respiratory disease in China at the end of 2019. It then spread with enormous rapidity and by mid-March 2020 was declared a world pandemic. Gilles de la Tourette Syndrome (GTS) is a childhood-onset neurodevelopmental disorder with a worldwide prevalence of about 1% of the population. The clinical symptoms include multiple motor and one or more phonic (vocal) tics. Germane to this communication is that 85% of patients with GTS have associated psychiatric co-morbidities, many of which are being exacerbated in the current global health crisis. In addition, several symptoms of GTS may mimic COVID-19, such as a dry cough and sniffing (phonic tics), while other symptoms such as spitting, inappropriate touching of others and "non-obscene socially inappropriate symptoms" can potentially get patients with GTS into trouble with the law. We suggest that a clear explanation of the COVID-19 illness and GTS is important to enable colleagues of various specialities who tend to patients with GTS. It is important to acknowledge at the outset that the information available on the COVID-19 pandemic changes daily, including cases infected, deaths reported, and how various national health systems are planning and or coping or not. It is fair to say that having read the current medical and lay press we conclude that it is not easy to reassure our patients with absolute certainty. However, notwithstanding that, we hope our documentation is of some assistance.