The COVID-19 pandemic and social distancing requirements abruptly changed the way we practice Movement Disorders including Parkinson’s disease (PD). The use of telemedicine became an important mode of providing care to people affected by PD. Over 40% of people with PD in one study stated they would like to continue using some telemedicine even after the pandemic is over (1). However, whether a NEW diagnosis of PD can be made and physicians can provide appropriate management plan and counseling by telemedicine remains unanswered. To deliberate these questions, I invited three discussants. Dr. T. Poplar (pseudonym) is a physician who was diagnosed and treated remotely during the COVID-19 pandemic. Dr. Ray Dorsey is a leading clinician researcher whose research focus is telemedicine and Dr. Stanley Fahn is an esteemed clinician researcher who established the foundation for our understanding of the phenomenology of movement disorders including Parkinson’s disease.
Dr. Poplar, can you describe your experience with receiving PD diagnosis and treatment via telemedicine?
I am a physician in my 60s, who first developed symptoms within the past year, starting with a tremor in one leg. I was not able to get an appointment in person with my preferred neurologist for several months. Then, unfortunately, the COVID-19 pandemic started, closing down most in-office appointments. However, fortunately for me, telehealth visits opened up and I was able to schedule an appointment expeditiously. Even at that early stage, my neurologist was able to easily diagnose PD through the history and physical examination carried out via videoconference. With the diagnosis secure, treatment was started. I was also referred to a physical therapist, who saw me via telehealth and started a program of exercises and follow up telehealth visits, which were extremely helpful. I have since then had a few follow up telehealth visits and, as my symptoms progressed, so did the treatments. Throughout it all, I felt that the telehealth visits were convenient and very efficacious.
Would in person examinations be even better? Perhaps so. Nevertheless, I found the visits to be effective and satisfying. Telehealth saved me hours of traveling time for each visit and made timely follow up care more accessible. I greatly appreciated having that option.
Dr. Dorsey. can you make a PD diagnosis in a telemedicine visit?
In most cases, yes. In general, studies indicate that 80% of diagnoses (for any condition) are based on history, 10% on physical examination, and the balance on diagnostic testing (e.g., labs, imaging). The history can readily be obtained via telemedicine and in many cases, more effective when conducted in a patient’s natural environment. The exam done remotely is quite simply not as good as it is in person. That said, for Parkinson’s disease, much of the exam is done by observation. Indeed, with the exception of assessments of rigidity and balance, the entire motor examination of the MDS-UPDRS can and is routinely performed remotely.
In addition, in most cases, the diagnosis of Parkinson’s disease is relatively straightforward. A history of an asymmetric rest tremor, slowness of movement, loss of smell, and constipation in a middle aged person generates a very short list of differential diagnostic considerations. Moreover, as the disease progresses, the diagnosis of Parkinson’s disease can be, according to Sir William Osler, “made at a glance.”
That said, many cases are far from clear, and a detailed, and often repeated, examination is needed. Diagnostic testing, including a DAT scan or genetic testing, may be helpful. A closer, more intimate connection that an in-person visit can offer may be required. Time may simply be needed as we know that early diagnosis even in the best of hands can be wrong about 10% of the time.
Finally, we need to shift our focus from what telemedicine cannot do to what it can. In less than a month in the U.S., telemedicine visits for Medicare beneficiaries increased 100-fold. Absent telemedicine, many of our existing patients would have received little, if any care. For many, no neurological care is the rule, not the exception. Over 40% of Medicare beneficiaries with Parkinson’s disease do not see a neurologist of any kind within four years of diagnosis, and those that do not have worse health outcomes.
We can use the new technologies of this century to vastly expand our reach, especially to populations that have long been underserved. In addition, we can think and develop new care models that might allow one Parkinson’s specialist, for example, to connect to many patients with Parkinson’s disease or allow for expanded access to clinicians from multiple disciplines (e.g., physical therapy, dieticians). Today, a physical therapist at Harvard conducts 100-person exercise classes for patients with Parkinson’s disease, including for one of mine in rural, upstate New York. Such patient-centered care was previously unimaginable. The future awaits us.
Can you make a new diagnosis of PD on a telemedicine visit?
Stanley Fahn, MD, New York. NY, U.S.A.
The answer is a qualified “yes” because it depends on the subtlety or severity of the clinical signs. With extremely subtle signs, as occurs at the onset on non-tremulous PD, even a face-to-face detailed examination can fail to establish a firm diagnosis of PD (or other forms of parkinsonism). However, with just the slightest amount of visible tremor-at-rest, the diagnosis is usually easily ascertained. For proof, I’ll cite two examples. First, we need look no further than the first medical publication on PD, namely James Parkinson’s An Essay on the Shaking Palsy (2). Parkinson described six people with the disease now bearing his name. Three were examined in person, the other three were observed walking in the streets of London. These three casually observed individuals had the characteristic tremor and flexed posture; one also had a slow, shuffling gait, and the other two had gait festination.
The second example is the diagnosis of PD (or possibly post-encephalitic parkinsonism) made from a newsreel in World War II. The newsreel briefly captured Adolf Hitler’s left hand rest tremor when he was walking slowly while shaking hands (with his right hand) with lined-up German army officers (3). This scene is shown again in a subsequent article (4). There have been other writings describing Hitler’s parkinsonism (5,6), but the actual cinema footage of the rest tremor (3,4) is the most convincing evidence. No other examination needed.
Even in non-tremulous PD, as long as there are obvious motor signs of bradykinesia, rigidity, masked faces, flexed posture, shuffling gait, festination, or freezing of gait, the diagnosis can be made from a distance. For proof of this statement, I’ll provide two personal experiences.
First anecdote: One evening I was walking in my village and spotted a man about 20 meters ahead of me walking in the same direction. I noticed his slow, shortened pace, slightly flexed posture and lack of arm swing. There was no tremor, but the other features indicated he had parkinsonism. Because of his slow gait, I caught up with him and recognized him as an acquaintance I seldom encounter. I had to decide quickly whether or not to inform him of my diagnostic impression, and decided that it was in his best interest for me to do so. After I explained my observations, I suggested he see one of my parkinsonologist colleagues for a definitive diagnosis and clinical care. He was thankful for my concern; it had not occurred to him that PD was responsible for his slowing down. He saw my colleague and improved with levodopa treatment and did well.
The second situation involves a professional colleague whose voice became soft and his gestures reduced, raising my suspicions of early PD. Several weeks later, a clear-cut rest tremor in one hand appeared while he was talking in front of a group. I decided the right thing to do was to speak to him after the other attendees departed from the room and to inform him of my observations. He was grateful for my insight and concern. He requested my assistance and came under my care. Fortunately, he had a good response to levodopa therapy with supplemental alprazolam that he takes whenever he needs to present before a group. This simple treatment has allowed him to continue his academic career and provide him relief from stress anxiety-induced augmentation of his tremor, as well as feeling his condition is under control.
Clearly, a video telemedicine visit allows much more detailed observations than a few seconds or minutes of a distant observation, as illustrated in all the above examples. So, telemedicine presents a better opportunity to make a diagnosis of PD than running into someone casually. After the early subtle stage of PD, the clinical motor features will become sufficiently prominent for most clinicians to make a diagnosis of PD during a telemedicine visit. The differential diagnoses of other forms of parkinsonism will always arise, whether during a televisit or with an in-person evaluation. The latter allows for more detailed examination (e.g., Pull Test and OKN testing) that might permit the clinician to make an alternate parkinsonian diagnosis, such as MSA or PSP. Clinicians today are fortunate to have available the technology of telemedicine to enable them to make a diagnosis of PD in most situations.
REFERENCES
- Feeney MP, Xu Y, Surface M, Shah H, Vanegas-Arroyave N, Chan AK, Delaney E, Przedborski S, Beck JC, Alcalay RN. The impact of COVID-19 and social distancing on people with Parkinson's disease: a survey study. NPJ Parkinsons Dis. 2021 Jan 21;7(1):10. doi: 10.1038/s41531-020-00153-8. PMID: 33479241; PMCID: PMC7820020.
- Parkinson J: An Essay on the Shaking Palsy, London, Sherwood, Neely, and Jones, 1817.
- Hägglund JV. Hitler's Parkinson's disease: a videotape illustration. Mov Disord. 1992 Oct;7(4):383-4. doi: 10.1002/mds.870070418. PMID: 1484538.
- Lieberman A. Hitler's Parkinson's disease began in 1933. Mov Disord. 1997 Mar;12(2):239-40. doi: 10.1002/mds.870120216. PMID: 9087984.
- Lieberman A. Adolf Hitler had post-encephalitic parkinsonism. Parkinsonism Relat Disord. 1996 Apr;2(2):95-103. doi: 10.1016/1353-8020(96)00005-3. PMID: 18591024.
- Bhattacharyya KB. Adolf Hitler and His Parkinsonism. Ann Indian Acad Neurol. 2015 Oct-Dec;18(4):387-90. doi: 10.4103/0972-2327.169536. PMID: 26713007; PMCID: PMC4683874.