INTRODUCTION
Telemedicine in neurology has developed with the advent of technology, which provided
an opportunity for knowledge transfer and information sharing. The applications of
technology enable patient care, teaching and training of professionals and research
development[1]. Telemedicine allows the provision of health services at a distance using technologies
for connectivity, including telephone and internet, and may involve teleconsultation,
teleconference, or even tele-education. Contact can be initiated by healthcare professionals
or patients and can be synchronous (in real-time) or asynchronous (store and forward)[2].
In December 2019, a new type of coronavirus, now known as SARS-CoV-2 (), was identified
in China. SARS-CoV-2 infection (COVID 19) caused severe respiratory conditions and
was associated with ICU admission and high mortality[3]. On March 11 2020 the World Health Organization characterized COVID-19 as a pandemic[4]. The pandemic has had a major socioeconomic impact and caused collapses in health
systems around the world. Social distancing and the lockdown promoted a change in
the offer of health care and the development of telemedicine. The COVID-19 pandemic
highlights how neurological care was provided and how the mode of delivery needed
to adapt quickly during this period, and how technology was fundamental in this process[5].
The aim of this study was to evaluate the number of publications on telemedicine in
neurology in the last two decades in PubMed and the available evidence on the use
of this technology in neurological clinical conditions.
DISCUSSION
The emergence and consolidation of teleneurology is closely linked to the evidence
for the benefit of stroke reperfusion therapies published in the 1990s[6]. The perception that every minute of delay in thrombolysis decreases the effectiveness
of treatment and increases the risk of complications is promoted with the slogan “time
is brain”[7]. In this context, where every effort is made to reduce the time between the onset
of symptoms and the start of reperfusion therapy, telestroke allows remote specialists
to indicate thrombolysis through information provided by the hospital physician, close
to the patient[8].
During the last two decades, the telestroke concept has spread around the world and
been refined. Mobile stroke units were developed to optimize pre-hospital care. They
are ambulances specially equipped with computed tomography, a point-of-care laboratory
for blood analysis, medication and an interdisciplinary team. Telemedicine allows
the support of a stroke specialist and, if indicated, thrombolysis can be started
in the ambulance, before arrival at the hospital[9].
Scientific evidence shows that stroke treatment has benefited from the digital health
revolution. The use of teleneurology for stroke has significantly impacted the acute
treatment of cerebrovascular diseases in many areas[10].
Several experiences and a few randomized trials have been published on remote consultation
between neurologists and patients with chronic neurological diseases. Patients suffering
from headache were evaluated and studies showed that the use of telemedicine was not
inferior to face-to-face care in terms of reducing attacks and recognizing secondary
headaches[11]-[13].
Evidence in the literature demonstrates that telemedicine care, through video or telephone
interviews, is suitable for people with epilepsy. Outpatient epilepsy follow-up consultations
depend essentially on phenomenological interviews, adherence to treatment and counseling,
and not on physical examination. Studies have shown similar patterns of seizure control
and medication adherence among patients with face-to-face and remote care[14],[15].
An important aspect evaluated in studies with telemedicine and cognitive impairment
includes the diagnostic reliability of the administration of cognitive tests, such
as the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination,
showing that scores obtained remotely and face-to-face are comparable[16]-[19].
Other studies indicate that telemedicine is a useful tool on the management of patients
with dementia[20]-[22], movement disorders[23],[24], including deep brain stimulation (DBS)[25],[26] follow-up, and in the attention of their caregivers[27].
The neurological examination involved in neuromuscular diseases has some items that
are difficult to access by telemedicine, such as reflexes and vibratory sense. The
same happens with vestibular disorders, with positional maneuvers, for example[28]. Before the COVID-19 pandemic, remote consultation in these areas was less consolidated.
In the last two years, however, experience with this type of care has increased and
telemedicine has been encouraged[29]. Current evidence indicates that telemedicine is a potential tool to be used as
a complement to face-to face consultations in numerous areas of neurology[30].
The development of telemedicine in neurology for chronic diseases is mainly motivated
by the difficulty of access to the specialists in some regions. In several countries,
there is a greater supply of specialists in capitals or tertiary services, which makes
access difficult for rural populations or locations with greater distances from large
centers. Access to care is also limited by patients' disabilities, as many neurologic
conditions impair mobility and driving abilities.
Telemedicine can have a positive impact on ensuring timely neurological care in inpatient
or outpatient across different healthcare systems. The impact of the distance of access
to the neurologist and the use of real-time video to promote timely access was the
subject of the cohort study developed by Craig et al. in 2004. The study highlighted
the difficulty of accessing specialist neurology consultations at two rural hospitals
in Northern Ireland, with general physicians providing local care and referring patients
to specialists when needed. Offering an early neurological consultation through real-time
video was an alternative to promote access in a shorter waiting time for the neurologist
with reduced hospitalization time[31].
Reducing the waiting time for consultation with the neurologist was also the subject
of the retrospective cohort by Constanzo et al. in 2020, involving analysis of primary
and secondary care referrals of 8269 patients to neurology. Waiting time for the first
consultation was 60% shorter for patients enrolled in the Teleneurology program in
Chile, a country with great distances from some locations to access the capital, Santiago,
the city with the highest concentration of neurologists[32].
A program that allows primary care providers (PCP) to maintain direct contact with
neurologists (eConsult service) in Canada has reduced the need for specialist consultation
by more than 30%. The neurologist's answers to PCP questions can guide the management
of patients with neurological complaints in primary care, which reduces the waiting
time for patients who need a formal consultation with a neurologist[33].
There is evidence showing benefits of telerehabilitation specially in patients after
stroke[34]-[36], but also in other neurological conditions, such as Parkinson disease[37], vestibular disorders[38] and multiple sclerosis[39]. Telerehabilitation is characterized not only by video contact between patient and
physical therapist, but can include virtual reality and applications for self-managed
exercises[36],[38], without therapist guidance. Telemedicine is useful in improving access to rehabilitation
therapy and reducing travel time and costs.
Telemonitoring is already a reality and an increasingly promising area. It is possible
to use portable vital signs measurement devices[40], wearable sensors and smartphone apps to detect information and send to the doctor
synchronously, 24 hours a day. It helps in the diagnosis, the assessment of the severity
of neurological diseases and supports clinical decision making. Smartphones can capture
voice and tremor and, and through machine learning, we can monitor or even diagnose
Parkinson’s disease[41]-[43]. Assessing balance and risk of falls using a validated smartphone app can increase
safety and reduce the number of falls in older adults[44].
In the near future, a set of quantitative measures derived from wearables or apps
could be considered digital biomarkers of a disease, contributing to early diagnosis,
stratification of subgroups and prediction of treatment outcomes[45].
In addition to the application of telemedicine among healthcare professionals and
between healthcare professionals and patients, teleneurology is also useful in education.
An experience has shown that supervising neurology training with robot[46] telepresence is feasible and remote consultations can be more comfortable for students
and patients for teaching anamnesis and neurological diagnosis[47].
The COVID-19 pandemic, with the recommendation of social distancing and the implementation
of lockdown in several countries, was an important factor in the development of telemedicine
to guarantee access to the first consultation and maintenance of patient follow-up.
Ganapathy highlighted in its descriptive study in 2020, about telemedicine and neurological
practice in the period of COVID-19, that real-time video synchronous queries or asynchronous
digital store-and-forward services can be used. The latter includes text messages,
WhatsApp communication and email. Remote monitoring of patient data can include viewing
images and neurophysiological parameters[5].
The pandemic has certainly made Digital Health a necessity and no longer an exception.
Technological advances that seemed distant possibilities and futuristic concepts came
to fruition in a short period of time due to the needs imposed by the COVID-19 pandemic[10].
Teleneurology in Brazil
There are few Brazilian publications about teleneurology. A recent survey[30] showed that before the pandemic only 18.5% of Brazilian neurologists worked with
telemedicine and 31.7% studied telemedicine, while 63.6% reported working with telemedicine
during the first year of pandemic[30].
Telestroke is a reality in some Brazilian cities, but it is necessary to improve stroke
care in all regions of the country, and the implementation of telemedicine support
is recommended for hospitals without neurologists available 24 hours a day[48],[49].
Several medical specialties have been included in government telemedicine programs
with the aim of supporting primary care physicians and optimizing referrals for each
specialty[50],[51]. Mantese et al. evaluated 1,687 teleconsultations on patients with neurological
complaints and showed that telehealth support could avoid 29% of referrals for neurology.
The main reason for teleconsultation was epilepsy or seizure (25%), followed by headache
(20%), stroke (10%), tremor or parkinsonism (7%) and cognitive disorders (6%)[52].
In Brazil, some telemedicine procedures, such as remote consultations, were not regulated
until ordinance 467 of the Ministry of Health[53] and Law 13.989, of April 2020[54], during the COVID-19 pandemic. After regulation, public and private health services
organized remote consultations and several studies are now being submitted for publication.
A descriptive study on telehealth in Recife during the COVID-19 pandemic included
126 remote neurological consultations and showed that in 68 the patient did not need
to be referred to specialized face-to-face care after the consultation, with follow-up
possible in primary care[55]. The authors are aware of different initiatives in teleneurology during the pandemic
and we believe that Brazilian publications on telemedicine will increase significantly
soon.
In conclusion, in the last two decades, teleneurology has been developing through
the expansion of technological resources. The COVID-19 pandemic intensified this process
and allowed for greater use of teleneurology to assist patients and to discuss cases
between doctors at different levels of health care. Different modalities of teleneurology
are studied in several neurology subfields and include teleconsultation (between healthcare
professionals or between healthcare professional and patient), telerehabilitation,
telemonitoring, tele-education.
The last two years have certainly made Digital Health a necessity and no longer an
exception. Technological advances that seemed distant possibilities and futuristic
concepts came to fruition in a short period of time due to the needs imposed by the
pandemic. 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.
