Telehealth utilization and patient satisfaction in an ambulatory movement disorders center during the COVID-19 pandemic.

INTRODUCTION: Studies suggest that patients are satisfied with telehealth in ambulatory settings. However, tele-neurology satisfaction data are limited by a small sample size and COVID-19-era data is not specific to movement disorders clinics. In this prospective observational study, telehealth utilization during the COVID-19 pandemic was assessed, and patient satisfaction was compared between telehealth and in-person visits in an outpatient movement disorders center. METHODS: Patients ≥18 years who completed an appointment at Northwestern's Movement Disorders Clinic were invited to complete a post-visit Medallia survey. The primary outcomes of the survey were likelihood to recommend (LTR) provider, LTR location, and 'spent enough time,' on a 0-10 scale. Responses were categorized into in-person vs. telehealth groups. RESULTS: Telehealth utilization significantly increased from a pre-COVID timeframe rate of 0.3% (Nov 2019 to Feb 2020) to 39.5% during the COVID-19 pandemic (March 2020 through April 2021) (p-value < 0.001). During the COVID-19 pandemic, 621 patients responded to the post-visit Medallia survey (response rate = 30%), including 365 in-person and 256 telehealth visits. No significant differences were observed between in-person and telehealth encounters in LTR provider (p = 0.892), LTR location (p = 0.659), and time spent (p = 0.395). Additional subgroup multivariable analysis did not support differences in satisfaction between different age groups. DISCUSSION: With its large sample size, our study demonstrates that in the setting of increased TH utilization in movement disorders clinic during the COVID-19 pandemic, patients reported similar satisfaction with telehealth compared to in-person visits. This study supports the utility of telehealth to provide specialized neurologic clinic care.

Study in Parkinson's disease of exercise phase 3 (SPARX3): study protocol for a randomized controlled trial.

BACKGROUND: To date, no medication has slowed the progression of Parkinson's disease (PD). Preclinical, epidemiological, and experimental data on humans all support many benefits of endurance exercise among persons with PD. The key question is whether there is a definitive additional benefit of exercising at high intensity, in terms of slowing disease progression, beyond the well-documented benefit of endurance training on a treadmill for fitness, gait, and functional mobility. This study will determine the efficacy of high-intensity endurance exercise as first-line therapy for persons diagnosed with PD within 3 years, and untreated with symptomatic therapy at baseline. METHODS: This is a multicenter, randomized, evaluator-blinded study of endurance exercise training. The exercise intervention will be delivered by treadmill at 2 doses over 18 months: moderate intensity (4 days/week for 30 min per session at 60-65% maximum heart rate) and high intensity (4 days/week for 30 min per session at 80-85% maximum heart rate). We will randomize 370 participants and follow them at multiple time points for 24 months. The primary outcome is the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score (Part III) with the primary analysis assessing the change in MDS-UPDRS motor score (Part III) over 12 months, or until initiation of symptomatic antiparkinsonian treatment if before 12 months. Secondary outcomes are striatal dopamine transporter binding, 6-min walk distance, number of daily steps, cognitive function, physical fitness, quality of life, time to initiate dopaminergic medication, circulating levels of C-reactive protein (CRP), and brain-derived neurotrophic factor (BDNF). Tertiary outcomes are walking stride length and turning velocity. DISCUSSION: SPARX3 is a Phase 3 clinical trial designed to determine the efficacy of high-intensity, endurance treadmill exercise to slow the progression of PD as measured by the MDS-UPDRS motor score. Establishing whether high-intensity endurance treadmill exercise can slow the progression of PD would mark a significant breakthrough in treating PD. It would have a meaningful impact on the quality of life of people with PD, their caregivers and public health. TRIAL REGISTRATION: ClinicalTrials.gov NCT04284436 . Registered on February 25, 2020.

High satisfaction and improved quality of life with Rock Steady Boxing in Parkinson's disease: results of a large-scale survey.

PURPOSE: To compare demographics, self-reported symptom burden, Health-Related Quality of Life (HRQL), and Self-Efficacy for Exercise (SEE) between participants and non-participants of Rock Steady Boxing (RSB), a non-contact boxing program for individuals with Parkinson's disease (PD) that focuses on agility, balance, and speed training. MATERIALS AND METHODS: Adults with PD who had heard of RSB completed a 20 min, 61-question electronic survey including the Parkinson's Disease Questionnaire-39 (PDQ-39) and the Self-Efficacy for Exercise (SEE) scale. Differences between participants and never-participants were analyzed using chi-squared test, fisher's exact test and Wilcoxon test. RESULTS: Of 2054 individuals enrolled in the survey, 1709 were eligible for analysis. 1333 were current participants, 166 previous-participants, and 210 never-participants. RSB participants were median age 69, 59% male, and 97% Caucasian. The majority of current participants reported that RSB improved their social life (70%), fatigue (63%), fear of falling (62%), depression (60%), and anxiety (59%). Compared to previous and never-participants, current participants had better median PDQ-39 scores (36 and 32 vs 25, p < 0.01) and SEE scores (43 and 48 vs 54, p < 0.01). CONCLUSIONS: This is the largest survey of RSB use in PD. RSB participants report improvement in non-motor impairments and have significantly better HRQL and ESE compared to never-participants.IMPLICATIONS FOR REHABILITATIONParkinson's disease (PD) is a slowly progressive neurodegenerative condition that affects motor function and subsequently, quality of life.Exercise is increasingly recognized as an important treatment for motor and non-motor symptoms of PD.Rock Steady Boxing (RSB) is a specific non-contact boxing program for PD that is growing and increasing in popularity, though there is limited data on its effect on PD symptoms and quality of life.

New dopaminergic therapies for PD motor complications.

BACKGROUND: Motor complications, characterized by "off" periods - when anti-parkinsonian medications are ineffective - and dyskinesia, are the hallmark of advanced Parkinson's disease (PD). While levodopa is the gold standard PD medication in terms of efficacy, its short duration of effect coupled with progressive loss of dopaminergic neurons leads to motor complications and fails to treat off periods. PURPOSE OF REVIEW: This review focuses on novel dopaminergic therapies that were recently made clinically available or are currently in development for the treatment of motor complications. First, it will discuss rescue therapies for the treatment of off episodes, including novel apomorphine and levodopa formulations. Second, it will highlight adjunctive dopaminergic medications approved to reduce total daily off time. Third, it will discuss longer-acting levodopa formulations in development and introduce a novel selective dopamine agonist under study. Finally, it will cover novel dopaminergic delivery mechanisms, with specific focus on continuous subcutaneous infusions in development. SUMMARY: The breadth of dopaminergic therapies recently approved or in development for motor complications, and specifically off time reduction, evokes cautious optimism. Gains in reducing off time with rescue therapies, adjunctive medications or longer-acting levodopa formulations are modest, and underscore the need for more continuous dopaminergic delivery to address the underlying pathophysiology and translate to clinically meaningful improvement in motor complications.

Tardive Dyskinesia in Older Persons Taking Antipsychotics.

Tardive dyskinesia (TD) is a hyperkinetic movement disorder caused by the use of dopamine receptor-blocking agents (DRBAs), a category of medications that includes first- and second-generation antipsychotics (APs) and agents such as metoclopramide that are used for the treatment of nausea and gastrointestinal dysmotility. While TD can affect people of all ages, older age is associated with increased risk of TD and also with the emergence of TD occurring after shorter treatment durations and lower dosages of DRBAs. TD is characterized by involuntary movements that include the face, limbs, and trunk, and is associated with increased comorbidities, social stigmatization, and impaired physical and mental health. Once present, TD tends to persist despite AP dose adjustment or discontinuation. Even with the use of US Food and Drug Administration (FDA)-approved medications for TD, symptoms may persist. Because the leading hypothesis for the pathophysiology of TD has been dysregulation of dopamine transmission due to treatment with DRBAs, APs that avoid postsynaptic dopamine receptor blockade may provide an alternative therapeutic approach for patients who require an AP. In this review, we discuss the risks, burdens, prevention, and management of TD, with a focus on older people.

A New Era: The Growth of Video-Based Visits for Remote Management of Persons with Parkinson's Disease.

The COVID-19 pandemic forced the abrupt and rapid expansion of an alternative care model that embraces the use of video-based visits in the care of persons with Parkinson's disease. Video-based visits not only eliminate the risk of infection but also reduce geography- and disability-related barriers to accessing specialist care. Research has established that they are feasible, acceptable to persons with Parkinson's disease and patient-centered. In the Unites States, the relaxation of licensure requirements, adoption of reimbursement parity and investment in telemedicine infrastructure has enabled the rapid growth of video-based visits during the COVID-19 pandemic. Now, we must turn our attention to ensuring that progress made in expanding access to video-based care is not lost and expanded worldwide. More work is needed to identify the optimal video-based care model, establish best practices, and ensure equitable access to care.

Formalizing a Residency Mentorship Program with a "Business of Medicine" Curriculum.

BACKGROUND: Mentorship is critical for achieving success in academic medicine and is also considered one of the core professional competencies for residency training. Despite its importance, there has been a decline in the mentor-mentee relationship, largely due to time constraints and lack of clear guidelines for productive discussions. We provide a mentorship curriculum with an easily adoptable workbook which may serve as a guide for programs seeking more formalized mentorship opportunities. METHODS: We created a mentorship curriculum that was divided into 4 quarterly sessions, each with topics to facilitate career guidance and development, and to provide insight into the practical aspects of business of medicine. The mentorship pilot curriculum was implemented during the 2017 to 2018 academic year. Specific questions were provided to stimulate reflection and appropriate discussion between resident mentee and faculty mentor. A post-curriculum survey was distributed to evaluate the effectiveness and satisfaction of the curriculum. RESULTS: A total of 23 residents participated in this pilot project. A majority had not had any formal teaching related to the business aspects of medicine (82%). Upon completion of the curriculum, most residents felt several topics were sufficiently covered, and a majority were satisfied with the course and relationship developed with their mentor (87%). CONCLUSIONS: Our pilot curriculum provides a model to address a knowledge gap in the practical aspects of medicine while simultaneously enhancing residency mentorship. The one-year course was generally well-received by residents and can serve as a model to other academic residency programs with similar challenges and goals.

Influence of Age of Onset on Huntington's Disease Phenotype.

Background: Older patients with Huntington's disease (HD) are often thought to have a slower progressing disease course with less behavioral symptoms than younger patients. However, phenotypic differences based on age of onset have not been well characterized in a large HD population. This study will determine the difference in manifestations and disease progression between patients with young, typical, and late onset adult HD at different stages of disease. Methods: Data obtained from Enroll-HD. Adults with manifest HD were included. Age groups were defined as young onset (YO: 20-29 years), typical onset (TO: 30-59 years), and late onset (LO: 60+ years). Subjects were categorized by TFC score, from Stage I (least severe) to Stage V (most severe). Motor, cognitive, and behavioral symptoms were analyzed. Descriptive statistics and Bonferroni p-value correction for pairwise comparison were calculated. Results: 7,311 manifest HD participants were included (612 YO, 5,776 TO, and 923 LO). The average decline in TFC score from baseline to second visit (1.5-2.5 years) was significantly faster for YO (-1.75 points) compared to TO (-1.23 points, p = 0.0105) or LO (-0.97 points, p = 0.0017). Motor deficits were worse for LO participants at early stages of HD, and worse for YO participants at advanced stages. YO and TO participants had greater burden of behavioral symptoms at early stages of disease compared to LO. Discussion: YO is predictive of a faster functional decline for adults with HD when compared to those with TO and LO. Motor and behavioral manifestations differ based on age of onset. Highlights: This study compares HD manifestations while controlling for disease severity, detailing robust phenotypic differences by age of onset alone. These findings have implications for the clinical management of HD symptoms and have the possibility to improve prognostic and treatment precision.