Remote video-based outcome measures of patients with Parkinson's disease after deep brain stimulation using smartphones: a pilot study

Modernizing the Staging of Parkinson Disease Using Digital Health Technology

Due to the complicated nature of Parkinson disease (PD), a number of subjective considerations (eg, staging schemes, clinical assessment tools, or questionnaires) on how best to assess clinical deficits and monitor clinical progression have been published; however, none of these considerations include a comprehensive, objective assessment of all functional areas of neurocognition affected by PD (eg, motor, memory, speech, language, executive function, autonomic function, sensory function, behavior, and sleep). This paper highlights the increasing use of digital health technology (eg, smartphones, tablets, and wearable devices) for the classification, staging, and monitoring of PD. Furthermore, this Viewpoint proposes a foundation for a new staging schema that builds from multiple clinically implemented scales (eg, Hoehn and Yahr Scale and Berg Balance Scale) for ease and homogeneity, while also implementing digital health technology to expand current staging protocols. This proposed staging system foundation aims to provide an objective, symptom-specific assessment of all functional areas of neurocognition via inherent device capabilities (eg, device sensors and human-device interactions). As individuals with PD may manifest different symptoms at different times across the spectrum of neurocognition, the modernization of assessments that include objective, symptom-specific monitoring is imperative for providing personalized medicine and maintaining individual quality of life.

Remote levodopa challenge test in Parkinson's disease: Feasibility, reliability, validity and economic value

BACKGROUND AND PURPOSE

The aim was to demonstrate the feasibility, reliability and validity of an in-home remote levodopa challenge test (LCT), as delivered through an online platform, for patients with Parkinson's disease (PwPD).

METHODS

Patients with Parkinson's disease eligible for deep brain stimulation surgery screening were enrolled. Participants sequentially received an in-home remote LCT and an in-hospital standard LCT (separated by 2.71 weeks). A modified Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III omitting rigidity and postural stability items was used in the remote LCT. The reliability of the remote LCT was evaluated using the intraclass correlation coefficient and the concurrent validity was evaluated using the Pearson's correlation coefficient r between the levodopa responsiveness of the remote and standard LCT.

RESULTS

Out of 106 PwPD screened, 80 (75.5%) completed both the remote and standard LCT. There was a good reliability (intraclass correlation coefficient 0.81, 95% confidence interval 0.69-0.88) and a strong correlation (r = 0.84, 95% confidence interval 0.77-0.90) between the levodopa responsiveness of the remote and standard LCT. The mean cost for PwPD was estimated to be reduced by 91% by using the remote LCT.

CONCLUSION

The remote LCT is feasible, reliable and valid and may reduce healthcare-related costs for PwPD and their caregivers.

Functional and Nonfunctional Requirements of Virtual Clinic Mobile Applications: A Systematic Review

Introduction: The Virtual Clinic Mobile Application (VCMA) is a valuable tool for managing and remotely monitoring patients with various medical conditions. It can alleviate the strain on outpatient services and offer follow-up options for patients who do not require a physical examination. A thorough understanding of recent literature can assist in identifying suitable functionalities for new development and future improvement of current applications (apps). This review study is aimed at identifying functional and nonfunctional requirements for VCMA. Methods: This study conducted a systematic search using databases such as PubMed, Scopus, ISI Web of Science, Science Direct, ProQuest, and IEEE to gather requirements of VCMA articles published in English from the inception of the databases up to April 2022. Out of a total of 1223 articles, 76 met the inclusion criteria. These articles were then analyzed using conventional content analysis to extract and categorize their requirements. Results: Two main themes and 8 subthemes in terms of VCMA requirements were extracted as follows: (1) functional requirements with 3 subthemes (demographic data documentation, health record, general features of the user interface (UI)); (2) nonfunctional requirements with 5 subthemes (usability, accessibility, compatibility, efficiency, and security). Conclusion: The findings highlight the importance of mHealth solutions for virtual care and the need for the development of apps based on the extracted functional and nonfunctional requirements for VCMA; however, controlled trials are necessary. It is recommended that transparent reporting of mHealth interventions be prioritized to enable effective interpretation of the extracted data.

"not one size fits all" The challenges of measuring paediatric health-related quality of life and the potential role of digital ecological momentary assessment: a qualitative study

PURPOSE

To explore the views of clinicians and researchers about the challenges of measuring health-related quality of life (HRQoL) in children (5-11 years) and to explore whether digital ecological momentary assessment (EMA) could enhance HRQoL measurement.

METHODS

Semi-structured qualitative interviews with 18 professionals (10 academics/researchers, four clinicians, four with both professional backgrounds) experienced in child HRQoL measurement. We analysed data thematically.

RESULTS

Theme One describes the uncertainty around conceptualising HRQoL for children and which domains to include; the greater immediacy and sensitivity of children's reflections on their HRQoL, leading to high variability of the construct; and the wide individual differences across childhood, incongruent with fixed HRQoL measures. Theme Two describes the challenges of proxy reporting, questioning whether proxies can meaningfully report a child's HRQoL and reflecting on discrepancies between child and proxy reporting. Theme Three covers the challenge of interpreting change in HRQoL over time; does a change in HRQoL reflect a change in health, or does this reflect developmental changes in how children report HRQoL. Theme Four discusses digital EMA for HRQoL data capture. In-the-moment, repeated measurement could provide rich data and address challenges of recall, ecological validity and variability; passive data could provide objective markers to supplement subjective responses; and technology could enable personalisation and child-centred design. However, participants also raised methodological, practical and ethical challenges of digital approaches.

CONCLUSION

Digital EMA may address some of the challenges of HRQoL data collection with children. We conclude by discussing potential future research to explore and develop this approach.

Towards full remote programming for deep brain stimulation in Parkinson's disease: A case series

People with Parkinson's disease (PwPD) who undergo deep brain stimulation (DBS) surgery could benefit from remote programming (RP), which has proven to be both effective and economical. However, there is limited research on PwPD with DBS implants who have completed all programming sessions exclusively through remote means (full remote programming, FRP). This case report documents the experiences of five PwPD who underwent FRP, with four demonstrating improvements in motor symptoms, quality of life, and medication reduction. A total of 22 postoperative programming sessions were conducted, all via RP. FRP integrates RP with online consultations. Our findings contribute preliminary evidence supporting the feasibility and safety of FRP in the postoperative care of PwPD with DBS implants.

Feasibility for evaluating motor aspects of Parkinson's disease through video consultations in a resource-limited setting in Southern Brazil

BACKGROUND

 Performing motor evaluations using videoconferencing for patients with Parkinson's disease (PD) is safe and feasible. However, the feasibility of these evaluations is not adequately studied in resource-limited settings.

OBJECTIVE

 To evaluate the feasibility of performing motor evaluations for patients with PD in a resource-limited setting.

METHODS

 The examiners rated motor aspects of parkinsonism of 34 patients with PD from the Brazilian public healthcare system through telemedicine with the patient's own means by using the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) rating scale. Quality measures of the video meeting were also obtained. The feasibility of rating the motor aspects was the primary outcome whereas the rating of individual motor aspects, video meeting quality and predictors of a complete evaluation served as secondary outcomes.

RESULTS

 The least assessable parameters were freezing of gait (52.9%), gait (70.6%), leg agility, and rest tremor (both 76.5%). Complete MDS-UPDRS part III was possible in 41.2% of patients and 62 out of 374 motor aspects evaluated (16.6%) were missed. Available physical space for a video evaluation was the worst quality measure. Incomplete evaluations were directly associated with disability (p = 0.048, r = 0.34) and inversely with available physical space (p = 0.003, r = 0.55).

CONCLUSION

 A significant portion of the MDS-UPDRS part III is unable to be performed during telemedicine-based evaluations in a real-life scenario of a resource-limited setting.

Remote scoring models of rigidity and postural stability of Parkinson's disease based on indirect motions and a low-cost RGB algorithm

Background and objectives

The Movement Disorder Society's Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS III) is mostly common used for assessing the motor symptoms of Parkinson's disease (PD). In remote circumstances, vision-based techniques have many strengths over wearable sensors. However, rigidity (item 3.3) and postural stability (item 3.12) in the MDS-UPDRS III cannot be assessed remotely since participants need to be touched by a trained examiner during testing. We developed the four scoring models of rigidity of the neck, rigidity of the lower extremities, rigidity of the upper extremities, and postural stability based on features extracted from other available and touchless motions.

Methods

The red, green, and blue (RGB) computer vision algorithm and machine learning were combined with other available motions from the MDS-UPDRS III evaluation. A total of 104 patients with PD were split into a train set (89 individuals) and a test set (15 individuals). The light gradient boosting machine (LightGBM) multiclassification model was trained. Weighted kappa (k), absolute accuracy (ACC ± 0), and Spearman's correlation coefficient (rho) were used to evaluate the performance of model.

Results

For model of rigidity of the upper extremities, k = 0.58 (moderate), ACC ± 0 = 0.73, and rho = 0.64 (moderate). For model of rigidity of the lower extremities, k = 0.66 (substantial), ACC ± 0 = 0.70, and rho = 0.76 (strong). For model of rigidity of the neck, k = 0.60 (moderate), ACC ± 0 = 0.73, and rho = 0.60 (moderate). For model of postural stability, k = 0.66 (substantial), ACC ± 0 = 0.73, and rho = 0.68 (moderate).

Conclusion

Our study can be meaningful for remote assessments, especially when people have to maintain social distance, e.g., in situations such as the coronavirus disease-2019 (COVID-19) pandemic.

Mobile internet-based mixed-reality interactive telecollaboration system for neurosurgical procedures: technical feasibility and clinical implementation

OBJECTIVE

To increase access to health interventions and healthcare services for patients in resource-constrained settings, strategies such as telemedicine must be implemented for the allocation of medical resources across geographic boundaries. Telecollaboration is the dominant form of surgical telemedicine. In this study, the authors report and evaluate a novel mobile internet-based mixed-reality interactive telecollaboration (MIMIT) system as a new paradigm for telemedicine and validate its clinical feasibility.

METHODS

The application of this system was demonstrated for long-distance, real-time collaboration of neuroendoscopic procedures. The system consists of a local video processing workstation, a head-mounted mixed-reality display device, and a mobile remote device, connected over mobile internet (4G or 5G), allowing global point-to-point communication. Using this system, 20 cases of neuroendoscopic surgery were performed and evaluated. The system setup, composite video latency, technical feasibility, clinical implementation, and future potential business model were analyzed and evaluated.

RESULTS

The MIMIT system allows two surgeons to perform complex visual and verbal communication during the operation. The average video delay time is 184.25 msec (range 160–230 msec) with 4G mobile internet, and 23.25 msec (range 20–26 msec) with 5G mobile internet. Excellent image resolution enabled remote neurosurgeons to visualize all critical anatomical structures intraoperatively. Remote instructors could easily make marks on the surgical view; then the composite image, as well as the audio conversation, was transferred to the local surgeon. In this way, a real-time, long-distance collaboration can occur. This system was used for 20 neuroendoscopic surgeries in various cities in China and even across countries (Boston, Massachusetts, to Jingzhou, China). Its simplicity and practicality have been recognized by both parties, and there were no technically related complications recorded.

CONCLUSIONS

The MIMIT system allows for real-time, long-distance telecollaborative neuroendoscopic procedures and surgical training through a commercially available and inexpensive system. It enables remote experts to implement real-time, long-distance intraoperative interaction to guide inexperienced local surgeons, thus integrating the best medical resources and possibly promoting both diagnosis and treatment. Moreover, it can popularize and improve neurosurgical endoscopy technology in more hospitals to benefit more patients, as well as more neurosurgeons.

Telemedicine in neurology: advances and possibilities

BACKGROUND

Telemedicine develops from technology that offers opportunities for knowledge transfer and information sharing and allows the provision of health services at a distance.

OBJECTIVE

To evaluate the number of publications on teleneurology in the last two decades in PubMed and the available evidence on the use of this technology in neurological clinical conditions.

METHODS

A quantitative assessment of publications related to telemedicine and neurology in the last two decades. A search was performed on the PubMed database for the descriptors ("Telemedicine"[Mesh]) AND "Neurology"[Mesh]). A review of the articles retrieved on the topic was carried out to evaluate the innovation processes used and applications in various clinical conditions involving teleneurology.

RESULTS

The search performed on March 14th 2022 resulted in 229 publications involving the topic of telemedicine and neurology between 1999 and 2022. Since 2000, there has been an increase in publications related to this topic, with a peak of 71 articles published in 2020, the year in which the World Health Organization defined the COVID-19 pandemic status.

CONCLUSION

In the last two decades, teleneurology has been developing through the expansion of technological resources and the COVID-19 pandemic intensified this process. Different modalities of teleneurology are studied in several neurology subfields and include teleconsultation (between healthcare professionals or between healthcare professionals and patients), telerehabilitation, telemonitoring and tele-education. The advances achieved by teleneurology in this period encouraged technological innovations and health processes that developed opportunities to improve the care provided in a mechanism of constant evolution.

Parkinson's disease and Covid-19: The effect and use of telemedicine

As a result of the Coronavirus Disease 2019 (Covid-19) pandemic the use of telemedicine and remote assessments for patients has increased exponentially, enabling healthcare professionals to reduce the need for in-person clinical visits and, consequently, reduce the exposure to the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). This development has been aided by increased guidance on digital health technologies and cybersecurity measures, as well as reimbursement options within healthcare systems. Having been able to continue to connect with people with Parkinson's Disease (PwP, PD) has been crucial, since many saw their symptoms worsen over the pandemic. Inspite of the success of telemedicine, sometimes even enabling delivery of treatment and research, further validation and a unified framework are necessary to measure the true benefit to both clinical outcomes and health economics. Moreover, the use of telemedicine seems to have been biased towards people from a white background, those with higher education, and reliable internet connections. As such, efforts should be pursued by being inclusive of all PwP, regardless of geographical area and ethnic background. In this chapter, we describe the effect he Covid-19 pandemic has had on the use of telemedicine for care and research in people with PD, the limiting factors for further rollout, and how telemedicine might develop further.