BACKGROUND: Genetic testing is essential to identify research participants for clinical trials enrolling people with Parkinson disease (PD) carrying a variant in the glucocerebrosidase (GBA) or leucine-rich repeat kinase 2 (LRRK2) genes. The limited availability of professionals trained in neurogenetics or genetic counseling is a major barrier to increased testing. Telehealth solutions to increase access to genetics education can help address issues around counselor availability and offer options to patients and family members.
OBJECTIVE: As an alternative to pretest genetic counseling, we developed a web-based genetics education tool focused on GBA and LRRK2 testing for PD called the Interactive Multimedia Approach to Genetic Counseling to Inform and Educate in Parkinson\'s Disease (IMAGINE-PD) and conducted user testing and usability testing. The objective was to conduct user and usability testing to obtain stakeholder feedback to improve IMAGINE-PD.
METHODS: Genetic counselors and PD and neurogenetics subject matter experts developed content for IMAGINE-PD specifically focused on GBA and LRRK2 genetic testing. Structured interviews were conducted with 11 movement disorder specialists and 13 patients with PD to evaluate the content of IMAGINE-PD in user testing and with 12 patients with PD to evaluate the usability of a high-fidelity prototype according to the US Department of Health and Human Services Research-Based Web Design & Usability Guidelines. Qualitative data analysis informed changes to create a final version of IMAGINE-PD.
RESULTS: Qualitative data were reviewed by 3 evaluators. Themes were identified from feedback data of movement disorder specialists and patients with PD in user testing in 3 areas: content such as the topics covered, function such as website navigation, and appearance such as pictures and colors. Similarly, qualitative analysis of usability testing feedback identified additional themes in these 3 areas. Key points of feedback were determined by consensus among reviewers considering the importance of the comment and the frequency of similar comments. Refinements were made to IMAGINE-PD based on consensus recommendations by evaluators within each theme at both user testing and usability testing phases to create a final version of IMAGINE-PD.
CONCLUSIONS: User testing for content review and usability testing have informed refinements to IMAGINE-PD to develop this focused, genetics education tool for GBA and LRRK2 testing. Comparison of this stakeholder-informed intervention to standard telegenetic counseling approaches is ongoing.

Patients with movement disorders such as Parkinson\'s disease (PD) living in remote and underserved areas often have limited access to specialized healthcare, while the feasibility and reliability of the video-based examination remains unclear. The aim of this narrative review is to examine which parts of remote neurological assessment are feasible and reliable in movement disorders. Clinical studies have demonstrated that most parts of the video-based neurological examination are feasible, even in the absence of a third party, including stance and gait-if an assistive device is not required-bradykinesia, tremor, dystonia, some ocular mobility parts, coordination, and gross muscle power and sensation assessment. Technical issues (video quality, internet connection, camera placement) might affect bradykinesia and tremor evaluation, especially in mild cases, possibly due to their rhythmic nature. Rigidity, postural instability and deep tendon reflexes cannot be remotely performed unless a trained healthcare professional is present. A modified version of incomplete Unified Parkinson\'s Disease Rating Scale (UPDRS)-III and a related equation lacking rigidity and pull testing items can reliably predict total UPDRS-III. UPDRS-II, -IV, Timed \"Up and Go\", and non-motor and quality of life scales can be administered remotely, while the remote Movement Disorder Society (MDS)-UPDRS-III requires further investigation. In conclusion, most parts of neurological examination can be performed virtually in PD, except for rigidity and postural instability, while technical issues might affect the assessment of mild bradykinesia and tremor. The combined use of wearable devices may at least partially compensate for these challenges in the future.

Background Telemedicine has been recognized as a viable solution for addressing the shortage of medical professionals in developing countries such as Nigeria. Tele-neurology has the potential to provide remote consultations and care for patients with neurological conditions, thereby reducing the burden of travel and improving access to medical care. Despite its growing popularity, there is a lack of research on patient\'s views on this mode of care delivery in Nigeria. This study was conducted to investigate patient\'s perspectives on the use of tele-neurology in Nigeria. Methodology A descriptive cross-sectional study was conducted among 398 neurology patients at Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria. The data obtained were analyzed using descriptive statistics and a chi-square test using p < 0.05. Results Only 3% of our respondents had previously used telemedicine, with 78.1% of the respondents open to using telemedicine as a means of consultation. The disadvantages of telemedicine noted include limitations in assessing neurological status (94.7%), difficulty in explaining health conditions (84.4%), and lack of technical support (14.6%). The majority of respondents (96.5%) believed telemedicine will help in saving time. There was a statistically significant association between propensity to use telemedicine and time spent in the hospital (0.045) and time off work (<0.001). The propensity to use telemedicine was statistically significant to the use of email (0.001) and type of email address (0.001). Conclusion The findings suggested that there is a need for healthcare providers and policymakers to invest in developing telemedicine to improve access to care.

BACKGROUND: Multiple sclerosis (MS) affects nearly 1 million people and is estimated to cost $85.4 billion in the United States annually. People with MS have significant barriers to receiving care and telemedicine could substantially improve access to specialized, comprehensive care. In cross-sectional analyses, telemedicine has been shown to be feasible, have high patient and clinician satisfaction, reduce patient costs and burden, and enable a reasonable assessment of disability. However, no studies exist evaluating the longitudinal impact of telemedicine care for MS. Here we describe the study protocol for VIRtual versus UsuAL In-office care for Multiple Sclerosis (VIRTUAL-MS). The main objective of the study is to evaluate the impact of telemedicine for MS care on: patient clinical outcomes, economic costs, patient, and clinician experience.
METHODS: This two-site randomized clinical trial will enroll 120 adults with a recent diagnosis of MS and randomize 1:1 to receive in-clinic vs. telemedicine care for 24 months. The primary outcome of the study is worsening in any one of the four Multiple Sclerosis Functional Composite 4 (MSFC4) measures at 24 months. Other study outcomes include patient and clinician satisfaction, major healthcare costs, Expanded Disability Status Scale, treatment adherence, and digital outcomes.
CONCLUSIONS: The results of this study will directly address the key gaps in knowledge about longitudinal telemedicine-enabled care in an MS population. It will inform clinical care implementation as well as design of trials in MS and other chronic conditions.
BACKGROUND: NCT05660187.

Background: Predicting the frequency of calls for telestroke and emergency teleneurology consultation is essential to prepare staffing for the immediate management of time-sensitive strokes. In this study, we evaluate Poisson distribution count data using a generalized linear model that predicts the volume of hourly telestroke calls over a 24-h period. Methods: We performed an Institutional Review Board approved retrospective cohort review of patients (January 2019-December 2022) from an institutional telestroke database at a large nonprofit multihospital system in the United States. All patients ≥18 years with a telestroke activation were included. Telestroke calls were quantified in frequency per day and analyzed by multiple time and date intervals. Poisson probability mass function (PMF) and cumulative distribution function (CDF) were used to predict call probabilities. A univariable Poisson regression model was fit to predict call volumes. Results: A total of 8,499 patients at 21 hospitals met inclusion criteria, the mean calls/day were 5.82 ± 2.54, and mean calls/day within each hour increment ranged from a minimum of 0.07 from 5 a.m. to 6 a.m. to a maximum of 0.45 from 7 p.m. to 8 p.m. The Poisson distribution was the most appropriate parametric probability model for these data, confirmed by the fit of the data to the expected distributions corresponding to the calculated means. The predicted probabilities of call frequencies by hour were calculated using the Poisson PMF and CDF; the probability of two or fewer calls/day by hour ranged from 98.9% to 99.9%. Univariable Poisson regression modeled an increase of future calls/day from 6.7 calls/day in July 2023 to 7.6 calls/day in October 2025. Conclusion: Poisson modeling closely fits telestroke call volumes, predicts the future volumes, and can be applied to any health system in which the mean call volume is known, which may inform the number of physicians needed to cover calls in real-time.

Background Teleneurology has been in existence for decades, and the COVID-19 pandemic has escalated its widespread usage. Neurological conditions are a leading cause of death globally, with sub-Saharan Africa bearing the bulk of the burden. Nigeria has few trained neurologists with the few available concentrated in an urban region. The adoption of teleneurology will help close this treatment gap. Despite evidence of its advantage, the adoption and state of teleneurology in Nigeria are very low. This study aims to determine the state and perception of teleneurology in the care of neurological patients in Nigeria and identify challenges to its wide usage. Methods The primary research method was a descriptive cross-sectional survey among 48 neurologists in Nigeria across the six geo-political zones of the country. Descriptive statistics such as frequency and percentage were used to summarize and present the results. Results A total of 48 neurologists participated, of which 46 (95.8%) specialized in general neurology. Videoconferencing is the most preferred means of telemedicine (24, 50%), followed by phone calls (16, 33.3%) and short messages (6, 12.5%). Three-quarters of the respondents are concerned about legal actions from telemedicine use. The majority (34, 70.9%) are not familiar with telemedicine tools, and 40 (83.3%) indicate low telemedicine seminar attendance. More than 90% (46) of neurologists believe that it is a viable approach and can save time and money. Barriers to telemedicine included the lack of incentive to use the technology (38, 79.2%), poor Internet connectivity (36, 75%), and the lack of exposure to telemedicine (36, 75%). Conclusions It is important to overcome the existing barrier to teleneurology in order to fully harness its potential in addressing the shortage of health professionals in Nigeria as most neurologists are open to using it.

Pediatric-onset multiple sclerosis (POMS) is the most common demyelinating disease in children. Patients suffer from physical disability, cognitive impairment, and psychosocial challenges. Management requires a multidisciplinary care team. Here we present a case of an 11-year-old boy with POMS who relocated to Guam prior to initiation of a disease-modifying treatment and who experienced a flare without immediate access to an MRI or a child neurologist. Care required the combined efforts of ophthalmology, pediatrics, and emergency medicine in Guam, real-time remote guidance by child neurology, and asynchronous collaboration with cardiology and child neurology. As a result, the immediate flare was accurately diagnosed and treated with steroids, the patient was started on Fingolimod, and an emergency management plan for future flares was constructed. This case illustrates the nuances of both the acute and chronic management of multiple sclerosis in a resource-limited setting and how a combination of synchronous and asynchronous telemedicine was able to achieve a satisfactory treatment plan.

BACKGROUND: Patient acceptability with outpatient teleneurology has been reported within specific conditions, but less is known about acceptability across neurologic conditions. The study objective was to compare the acceptability of teleneurology between patients with various neurological conditions and determine what other factors influence acceptability.
METHODS: This was a prospective study of Veterans who completed new outpatient teleneurology visits with the Department of Veterans Affairs National Teleneurology Program. Visits were conducted via video to home or video to the outpatient clinic. Patient acceptability was assessed via telephone interview two weeks post-visit. Acceptability was a summed score (3-21) of three 7-point Likert questions (higher = more acceptable). Clinical diagnosis categories were based on the neurologists\' ICD10 diagnosis code. Acceptability score was modeled using a censored Tobit model controlling for demographics, type of tele-visit, medical comorbidity, and ICD10 category.
RESULTS: In FY 2021, 277 of 637 (43.5%) patients completed an interview with analyzable acceptability data. Of these 277, 70 (25.3%) had codes indicating headache, 46 (16.6%) movement disorder, 45 (16.2%) general symptoms, and 116 (41.9%) for all other categories. Mean patient acceptability was 18.3 (SD 3.2). There was no significant difference in scores between these groups. The only factor independently related to acceptability was medical comorbidity, with higher comorbidity associated with higher acceptability scores.
CONCLUSIONS: Patients find their outpatient teleneurology experience highly acceptable independent of neurologic condition. Those with more comorbidity report higher acceptability. Use of teleneurology may be useful and acceptable across many outpatient neurologic conditions including for more medically complex patients.

BACKGROUND: Patients with neurodegenerative diseases who live in remote areas often have limited access to specialized healthcare, and telemedicine represents a useful solution. The aim of this study was to investigate the perceptions toward the use of a specialized-tertiary telemedicine service of patients with cognitive and movement disorders, caregivers, and local healthcare professionals (HPs) in the Aegean Islands.
METHODS: Data were derived from the \"Specialized Outpatient Clinic of Memory, Dementia and Parkinson\'s disease through the National Telemedicine Network\", March 2021-March 2023. The survey included 10 questions (5-point Likert scale).
RESULTS: We received 64 questionnaires (25 patients, 18 caregivers, 21 HPs). Most participants positively perceived all aspects of telemedicine, including comfort (mean ± standard deviation: patients 4.5 ± 0.9, caregivers: 4.8 ± 0.5, HPs: 4.6 ± 0.7), access to specialized care (4.7 ± 0.6, 4.7 ± 0.5, 4.9 ± 0.4), number of transportations (4.6 ± 0.8, 4.6 ± 0.9, 4.8 ± 0.5), adequacy of follow-up (4.6 ± 0.7, 4.4 ± 0.8, 4.2 ± 0.7), future telemedicine selection (4.8 ± 0.4, 4.8 ± 0.4, 4.6 ± 0.6), perceived reliable medical assessment (4.7 ± 0.5, 4.6 ± 0.6, 4.3 ± 0.6), information delivery (4.7 ± 0.6, 4.6 ± 0.5, 4.4 ± 0.9), health status improvement (4.6 ± 0.7, 4.6 ± 0.6, 4.0 ± 0.7), cost (4.6 ± 1, 4.6 ± 1, 5.0 ± 0.2), and general satisfaction (4.8 ± 0.4, 4.7 ± 0.5, 4.5 ± 0.6). The commonest recommendations were more frequent visits, medical specialties, and dissemination of information.
CONCLUSIONS: The positive perception of participants highlights the value of telemedicine for specialized healthcare for neurodegenerative disorders, especially in remote areas.

Teleneurology is a specialist field within the realm of telemedicine, which is dedicated to delivering neurological care and consultations through virtual encounters. Teleneurology has been successfully used in acute care (e.g., stroke) and outpatient evaluation for chronic neurological conditions such as epilepsy and headaches. However, for some neurologic entities like Parkinson\'s disease, in which an in-depth physical examination by palpating muscles and performing neurologic maneuvers is the mainstay of monitoring the effects of medication, the yield and feasibility of a virtual encounter are low. Therefore, in this prospective review, we discuss two promising teleneurology approaches and propose adjustments to enhance the value of virtual encounters by improving the validity of neurological examination: \'hybrid teleneurology\', which involves revising the workflow of virtual encounters; and \'artificial intelligence (AI)-assisted teleneurology\', namely the use of biosensors and wearables and data processing using AI.