Telemedicine in neurology

Concussion and TBI

Concussion, or mild TBI, is commonplace, and there is a dearth of physicians to provide evaluations of patients with these types of injuries, especially in rural areas (e.g., sports injuries at rural high schools).⁸ Diagnosis and care of concussion is crucial to prevent additional injury, morbidity, and mortality. Although concussion and TBI are beginning to be addressed by teleneurology, data on this use are limited.⁹

One study compared real-time diagnosis of concussion through teleneurology with onsite diagnosis in 11 collegiate football players by using the Standardized Assessment of Concussion, the King-Devick test, and the Balance Error Scoring System. Results of the study indicated that the diagnoses were within a statistically significant level of agreement across modalities and that there was no difference in scores on testing or removal-from-play decisions.¹⁰ A third study reported that, in sideline/locker room high school sports consultations, teleneurology for concussion was beneficial and well received by patients and caregivers.¹¹ It was most often used for return-to-play decisions and determining the need for further evaluation. However, clinicians reported a lower degree of satisfaction. Two studies demonstrated that, at 3 months after injury, counseling and education for patients with TBI over the telephone were better than in-person treatment with regard to decreasing symptom burden and impact of symptoms on daily functioning and improving quality of life.^12,13 In addition, these studies found that eventual vocational status, community integration status, and general health outcomes at 3 months were found to be equivalent between in-person treatment and teleneurology. In another telephone study, patients with TBI discharged from inpatient rehabilitation units who received 7 scheduled individualized telephone interventions over a 9-month period were found to exhibit lower depression symptom severities (with greater improvements for those with a higher burden of depression symptoms at baseline) compared to patients with in-person interventions over a 1-year period.¹⁴

There also is a vast need for concussion diagnosis support in military settings. Although there are suggestions for the use of remote imaging support, diagnosis, and care, there have not been studies on the efficacy of implementation. E-mail teleconsultations were implemented in military settings to recommend care plans for individuals with mild TBI and were found to be viable.¹⁵ The Department of Defense and the VA have successfully implemented telemedicine for mild TBI diagnosis, management of symptoms, return-to-duty decisions, and care via an electronic consultation service known as the tele-TBI clinic.¹⁶ In addition, general teleconsultations, educational materials, and remote therapy are used, among other methods of telemedicine, although research on their efficacy is lacking.

Dementia

Dementia is quite amenable to remote evaluation given that a large component of examination involves the interview. Current studies in teleneurology for dementia care suggest increased access, good diagnostic accuracy, patient and provider satisfaction, and possible cost savings. While most of the studies on teleneurology for dementia that the authors reviewed mentioned the potential role of teleneurology in increasing access to dementia specialists, no single study explicitly studied increased access as an outcome measure. One study¹⁷ reported that 17 of the 30 telemedicine clinic sessions described would likely have been canceled because of time constraints if the physician had to travel to the remote site, suggesting more reliable patient access with teleneurology. Another study highlighted that transportation barriers remain for patients who have to travel long distances to rural telemedicine clinics.¹⁸

Several studies of teleneurology for dementia focused on diagnostic accuracy and reliability of the administration of common screening tests.^19,–,23 Overall, diagnostic accuracy for dementia was comparable between teleneurology and in-person evaluations, with a reported 76% to 100% consistency rate, with common specific brief standardized measures being comparable between teleneurology and in-person evaluations.^{19,20,24,–,26}

Only 1 study²⁷ directly reported teleneurology vs in-person visit satisfaction. All the participants had experienced both teleneurology and in-person visits, and the patient-caregiver dyads reported comparable satisfaction across the 2 formats. Postencounter questionnaires or informal assessments of teleneurology (without comparison to in-person visits) indicate high satisfaction with teleneurology among patients and families,^24,28,–,30 as well as providers.^23,29,31

One study found no difference in 1-year rate decreases in Mini-Mental State Examination scores between in-person and teleneurology assessments, suggesting that teleneurology is at least as efficacious as in-person visits in terms of patient outcomes.³² Another found that patients who received treatment by teleneurology had significantly longer treatment duration than patients receiving in-person treatment, suggesting that compliance with visits was higher in the teleneurology group.³³ One study reported that 89% of the recommendations made by a virtual memory clinic were implemented by the referring provider,³¹ although this was not compared to the rate from a comparable in-person group.

Few studies included a cost-benefit analysis. In 1 study comparing teleneurology for dementia care to the cost of in-person care when the dementia expert had to travel to a rural clinic, cost analysis favored teleneurology for dementia only if the expert had to travel >2 hours.³⁴ Multiple studies reported indirect cost savings in terms of travel miles or time saved for both patients and providers. Although some just reported shorter drives without specific data,¹⁸ others reported specific savings such as an average of 213 km saved per visit²⁷ and an average of 67 miles and 74 minutes saved per visit.³⁰

In summary, only 7 of the 20 studies included were randomized clinical trials, limiting the interpretation of most of these findings. Going forward, better-designed studies with clear outcomes and comparison groups are needed to determine with certainty how teleneurology compares with in-person dementia care.

Epilepsy

The management of people with epilepsy (PWE) presents many unique challenges that can be successfully addressed by teleneurology. PWE often have restricted driving privileges that can hinder traveling for visits.^35,–,37 Follow-up outpatient epilepsy visits often focus on description of seizure semiology initially and seizure control, adherence, antiepileptic drug side effects, and counseling more than physical examination.³⁷ Furthermore, monitoring of serum antiepileptic drug serum levels, especially in pregnant women, may easily be done remotely.³⁵ The AAN epilepsy and seizure quality measure lists the consideration of referral for patients with medically refractory epilepsy to specialized epilepsy centers³⁸ that may be far from many communities.³⁵ Specialized epilepsy centers rely on communication and referral from community physicians to integrate care during both the evaluation for resective epilepsy surgery and the provision of chronic epilepsy care. EEGs and epilepsy monitoring unit recordings can be remotely interpreted and accessed in locations that lack specialized neurophysiologists.³⁵ Despite evidence-based recommendations, time to referral for epilepsy surgery has remained 18 to 23 years after the onset of habitual seizures.³⁹ Earlier access to specialized centers could improve access and outcomes.

Ample evidence in the literature supports the successful use of teleneurology for PWE. One study³⁵ demonstrated, in 74 telemedicine encounters, medication changes in 43% of patients and discussion of surgical options in 35% of patients, with a no-show rate of only 11% vs a no-show rate of 22% among the in-person seizure clinic group of the study. In a recent prospective randomized parallel study³⁷ with 465 stable PWE randomized to in-person vs telephone visits, there was no significant difference in the number of breakthrough seizures between the groups, and patient satisfaction for telephone visits was 90%. Another study³⁶ indicated no significant difference in number of seizures, hospitalizations, emergency room visits, or medication compliance between patients who sought care through a traditional ambulatory clinic in an academic medical center and patients who sought care through a telemedicine clinic. One study indicated that PWE perceive e-health tools as user friendly,⁴⁰ possibly suggesting that teleneurology for PWE may provide an acceptable model for management. In an era of increasing medical costs, teleneurology for PWE has also demonstrated health care system cost reductions for both patients and providers.^36,41

Headache

Headaches are one of the most common neurologic disorders. Because of the dearth of headache specialists, teleneurology for headache is gaining traction. In 1 study, a comparison of traditional, in-person consultations and teleneurology consultations indicated noninferiority of teleneurology visits.⁴² In addition, teleneurology was found to be an accurate method of diagnosing and treating nonacute headache, saving time and money, with 99% patient satisfaction. Compliance and improvement over time were not different between groups, but the teleneurology group had fewer follow-up visits.⁴³ In a follow-up study, these patients reported satisfaction with their telemedicine experience, which was comparable to their in-person counterparts.⁴⁴ In another study, the efficacy of psychophysiologic treatment through teleneurology for vascular headaches was examined in a small group, and results demonstrated that 3 of the 4 patients improved on the Headache Index, number of headache-free days, and peak headache intensity.⁴⁵ Furthermore, 2 patients reported significant reductions in prophylactic and analgesic medication use after treatment. Teleneurology in the form of interviews, medical image sharing, and videoconferencing in 1 study was found to be beneficial in the diagnosis of 1 individual with migraine.⁴⁶ In a pediatric population, teleneurology follow-up for headaches was found to be more convenient and cost-effective, with high patient and parent satisfaction.⁴⁷ One study of a small cohort of 8 pediatric patients demonstrated that outcomes were comparable between teleneurology and in-person visits, with high satisfaction.⁴⁸ In another study, teleneurology and in-person visits for migraines were also found to be equivalent with high patient approval.⁴⁹ Furthermore, a review of the literature on various implementations of teleneurology found that in 3 separate studies, outcomes of teleneurology visits were comparable to those of in-person visits.⁵⁰ Electronic headache diaries, on the other hand, have been shown to be more effective than traditional paper headache diaries for both the patient and the doctor.⁵¹

Although multiple studies have demonstrated favorable results in terms of noninferiority, convenience, and patient satisfaction, some studies were performed in artificial settings, did not evaluate full neurologic examinations or used a telepresenter as an extension of the physician, evaluated only a small number of patients, or examined only stable, unchanged nonacute headache, thus warranting further study for the broader headache category.

Movement disorders

Movement disorders are underrecognized, and there is a significant shortage of trained specialists.⁵² Teleneurology improves access to specialty care, allowing earlier diagnosis and skilled management of movement disorders,^53,–,56 as well as concomitant cognitive impairment⁵⁷ and psychiatric comorbidities.^58,–,60

Several studies showed noninferiority of teleneurology vs in-person evaluations and assessments with standardized scales, including the Unified Parkinson's Disease Rating Scale,^e1 Unified Huntington's Disease Rating Scale,^e2 and the Abnormal Involuntary Movement Scale.^e3 In addition, observational analysis of gait through teleneurology, even at low-bandwidth internet speeds, was found to be reliable compared with in-person evaluation.^e4 Even the review of 10-second video clips of gait allowed experienced geriatricians to reliably identify gait abnormalities.^e5 An evaluation of >1,000 patients, potentially with oromandibular dystonia, by a movement disorders specialist via live “cyberconsultation” showed that only 12.5% of patients had previously been diagnosed with dystonia.⁵⁴ In addition, results of a study comparing observation of preschool children with movement disorders through video clips of the children and in-person observations indicated significant agreement between the 2 forms of observation.^e6 Administration of the Montréal Cognitive Assessment by teleneurology in patients with Parkinson disease (PD)^57,e7 and Huntington disease^e7 has also produced reliable results. One study found no significant differences in quality of care or delivery of information, counseling, and support between groups who received predictive genetic testing for Huntington disease remotely or in person, suggesting that teleneurology may improve access to this service.^e8

Although diagnostic accuracy is important, demonstration of improvement in function is ideal. Two studies showed that a teleneurology evaluation for PD resulted in medication changes and referrals for therapy and support groups^e9 and that changes in medical care were suggested in 93% of initial telemedicine encounters between nursing home residents and a movement disorders specialist.^e10 Furthermore, for patients with PD in a long-term care facility, the average cost per visit for those examined through teleneurology was significantly lower than that for patients examined in person.^e11 In addition, a 30-day program during which neurologists reviewed several self-recorded videos of patients with PD and recommended treatment changes resulted in a 7-point improvement in Unified Parkinson's Disease Rating Scale motor scores.^e12 A national randomized controlled trial of teleneurology vs in-person care for patients with PD found that teleneurology house calls are feasible, with no worsening clinical outcomes, emergency room visits, hospitalizations, or caregiver burden.^e13,e14 In addition, improvement in depression and anxiety in patients with PD who have received telephone-based cognitive-behavioral therapy^58,59,e15 and reduction in tic frequency in patients with PD who have received behavioral teletherapy⁵⁶ have also been demonstrated. Postoperative follow-up for deep brain stimulation device placement puts a significant burden on patients and families, especially in remote locations. Two studies demonstrated the effectiveness of teleneurology evaluation and remote deep brain stimulation device adjustment in patients with PD in remote areas of China.^e16,e17

Two studies reported overall satisfaction with teleneurology evaluations, including greater satisfaction with convenience and accessibility^e11,e18 and reduced travel burden. Another study showed that videophone visits to educate patients about complicated medication regimens and self-management were more useful for nurses and more satisfying to patients compared with telephone-only visits.^e19

The interest in telemedicine is seen in both urban and nonurban regions, with half of all participants expressing interest in a study in Australia.^e20 While there was generally wide acceptance across many of the studies, there were reports of time requirements^e21 and ineffective evaluations of children with complex movement and postural disorders due to poor video quality.^e22 However, store-and-forward evaluation of video recordings in the latter study was successful.

Multiple sclerosis

The cumulative burden of disability in MS can make traveling to MS specialty centers increasingly difficult for patients, thus making telemedicine an attractive option. Few studies explicitly compared teleneurology with in-person visits in terms of access to health care for patients with MS. One study reported that video visits were shorter and more focused on specific topics.^e23 Visits occurred in patients' homes or work and saved an average of 258 km in travel, reduced missed workdays by 65%, reduced costs of overnight lodging by 17%, and avoided airfare for 1 patient. Caregiver burden was also reduced. Another study reported that each cognitive testing session administered through teleneurology saved more than $144 in travel costs and lost wages compared with in-person testing.^e24

Among studies evaluating diagnostic accuracy, 4 evaluated the accuracy of televideo-enabled administration of the Expanded Disability Status Scale (EDSS) vs in-person administration. Two of the studies conducted as a component of the VA Home Automated Telemanagement system relied on a telepresenter. One showed high correlation between remote evaluators,^e25 and both showed good agreement between remote and in-person evaluators.^e25,e26 Another study compared an in-person EDSS evaluation to a multimodal remote examination that included a video of previously trained participants' self-administered neurologic evaluation, as well as patient-reported questionnaires and other components.^e27 There was modest agreement between conventional and multimedia formats for EDSS score ≤4.0 (κ = 0.2) and good for EDSS scores ≥4.5 (κ = 0.6). The fourth study compared an in-person EDSS evaluation with a televideo-enabled EDSS evaluation without a telepresenter and reported evaluation score agreement within 1 point for 88% of the visits.^e23 While not perfect, these studies suggest that the televideo-enabled administration of the EDSS could be used for periodic follow-up assessments. One systematic review reported accurate and reliable measurement of physical activity in patients with MS,^e28 including daily step count, over a range of ambulatory impairment.^e29 Remote cognitive evaluation demonstrated similar scores on automated neuropsychological assessment metrics among in-office, remote in-office, and in-home testing, although scores on the Symbol Digit Modalities Test were not similar.^e24

Provider and patient satisfaction was high with in-home and in-clinic teleneurology visits ^e23,e26 for cognitive testing,^e24 health promotion, ^e30,e31 and home-based management.^e32

Few studies evaluated the impact of teleneurology approaches on clinical outcomes such as hospitalizations, relapses, treatment adherence, and cost of care. Adherence to MS disease-modifying therapy was addressed in a series of analyses of the VA's MS Home Automated Telehealth system, showing that brief telephone-based counseling intervention leveraging principles of motivational interviewing and teleneurology home monitoring improved MS disease-modifying therapy adherence monitoring and outcomes.^e33–e35

The majority (27 of 44) of the studies reviewed focused on the use of teleneurology to improve specific domains of functioning, including mood, fatigue, physical activity, and overall quality of life. One randomized controlled trial reported improvement in physical activity after a 12-week trial of internet-delivered behavioral intervention supplemented with video coaching that was sustained during a 3-month follow-up.^e36 A follow-up study reported that fatigue and mood improved through the intervention.^e37 Specific aspects of physical activity such as balance appear to be effectively improved through these technologies.^e38 A recent Cochrane Review found low-level evidence for telerehabilitation to improve disability, fatigue, and quality of life and stated that “more robust trials are needed to build evidence for the clinical and cost effectiveness of these interventions.”^e39

Neuromuscular

The domain of neuromuscular conditions is wide and ranges between common diseases such as diabetic neuropathy and rare conditions such as periodic paralysis. Management of many neuromuscular conditions such as amyotrophic lateral sclerosis requires a comprehensive multidisciplinary approach. While there is rapid advancement in diagnostic technology, diagnosing many of these conditions requires detailed neurologic examinations to identify subtle findings that may not be easily appreciated during examinations through teleneurology. Patients with known diagnoses and whose symptoms are stable may benefit from telemedicine evaluation.

Only 4 studies for teleneurology in neuromuscular disorders met the inclusion criteria. Three unblinded mixed-methods studies focusing on patients with an established amyotrophic lateral sclerosis diagnosis found that teleneurology was generally viewed favorably by patients, caregivers, and health care providers and that patients were satisfied with teleneurology treatment.^e40–e42 The most common sentiment conveyed was that teleneurology removed the burdens of travel, resulting in lower stress and more comfortable interactions. Another small, unblinded study (n = 4) of patients with known advanced facioscapulohumeral muscular dystrophy found that teleneurology was acceptable among both patients and caregivers.^e43 Two studies that assessed the quality of teleneurology care through patient questionnaires reported that both patients and caregivers were satisfied with the clinical care that patients received via teleneurology, although acute care issues were never discussed.^e40,e41

Inpatient general neurology

There are limited data on the use of telemedicine for inpatient general neurology. Of the 22 articles about the use of teleneurology for inpatient general neurology that were reviewed by the authors, only 1 met the criteria for inclusion. This was a cohort study^e44 performed in 2 small rural hospitals for all patients >12 years of age who were admitted with neurologic symptoms over a 24-week period. Patients at one of the hospitals were offered consultation with a neurologist through teleneurology. Those patients had significantly shorter stays without any difference in diagnosis, mortality, or use of inpatient hospital resources or medical services in the follow-up period compared to patients in the hospital in which teleneurology consultation was not used, suggesting that early assessment by a neurologist using teleneurology may reduce the length of hospital stay without compromising diagnostic accuracy, mortality, or resource use.