Teleneurology for Parkinson’s disease and movement disorders in the COVID-19 pandemic

Introduction

Since its branching from internal medicine few decades ago, of which neurology once was a subspecialty itself, subspecialization of neurology has been marching forward at a great pace. As a result, today there are more than two dozen neurology subspecialties and up to three-quarters of graduating neurology residents continue to complete a clinical fellowship program in one of those subspecialties. One of those subspecialties is movement disorders. The term “movement disorders” in general use pertains to “Parkinson’s disease, related neurodegenerative and neurodevelopmental disorders, hyperkinetic movement disorders, and abnormalities in muscle tone and motor control”, and includes diseases such as dystonia, chorea, ataxia, Tourette syndrome, essential tremor, myoclonus, restless legs syndrome, and many others. While its subspecialty training curriculum is not currently stipulated by the Accreditation Council for Graduate Medical Education and thus movement disorder fellowship programs are not accredited like many others, the several dozen available clinical fellowship programs are usually formal and curriculum-based.

Parkinson’s disease (PD), arguably the most important movement disorder, is historically recognized via its four cardinal motor features (resting tremor, bradykinesia, rigidity, and postural instability) and played a pivotal role in the birth of “movement” disorder as a subspecialty field, due to its most recognized features related to impaired movements and motor control. Considering the importance of phenomenology of movement abnormalities, visual observation plays a fundamental role in diagnosing and managing patients with PD and other movement disorders. Therefore, videotaping and video evaluations have become an inevitable part of movement disorder care. It naturally follows that video or “virtual” visits, a pinnacle of telehealth, which allow such visual observation and examination of motor symptoms in movement disorders, represent a care delivery particularly relevant and appropriate in the care of movement disorder patients. Care in PD, relying on the use of virtual visits, was found to be noninferior in comparison to traditional care, including patient and provider satisfaction. Besides PD, telemedicine has been also used for hyperkinetic movement disorders and a wide range of other movement disorders including atypical parkinsonian syndromes, Huntington’s disease, and essential tremor.

In addition to the importance of video assessments (which can be technically done via virtual visits), objective measurements in PD and movement disorders, many of which technically and feasibly doable remotely, have been increasingly introduced in PD and movement disorder care. More recently, a new term, “digital phenotyping,” has been proposed to describe this novel domain of objective assessment of symptoms and findings in PD and movement disorders. Digital phenotyping represents a novel, critically important direction in the assessment and management of PD and movement disorders, considering its many advantages over traditional care: objectivity, lack of intra- and interrater variability, high reproducibility, feasibility of remote application, ecological validity, higher accuracy and finer grading compared to scales forcing scores into fewer, cruder, arbitrarily defined categories, and often a greater degree of automation.

The year 2020 witnessed unprecedented changes in Parkinson’s and movement disorder telehealth practices around the world due to the profound impact of the COVID-19 pandemic. Thanks to the many regulatory adjustments and easing, telehealth access have improved considerably since the start of the pandemic, with many of the financial and regulatory burdens having been eased significantly in no small part due to the CARES Act in the United States.

Deep brain stimulation (DBS) implants have been critical in the management of many movement disorder patients, most notably those with advanced and/or intractable PD, dystonia, and essential tremor (ET). The COVID-19 pandemic profoundly impacted DBS care. In addition, a recent survey (2020) has been conducted by the Motor Working Group of the Parkinson Study Group (PSG) in the United States on the impact of COVID-19 on clinical care, clinical research, and advanced therapy (such as DBS) practice adjustments among movement disorder specialists, and this work has been submitted as an abstract for the 2021 AAN Annual Meeting.