What exams are difficult to perform over telehealth?

[tulsajoe94]

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Hello!

I'm a MS1 in a biomed device/software design class focused on telehealth. I was wondering what tests neurologists do often but are finding difficult to do over telehealth.

For example, do you test the pupillary light reflex often? Or need to assess strength or sensation often?

Thanks for any feedback you can give! We're working w/ PM&R Docs now but know there is sometimes overlap here 🙂

 

[Telamir]

I only have experience with telestroke, and not with telehealth to do regular consults but I'll take a crack at it.

You're right in assuming that there are challenges with telehealth and certain parts of the exam. That being said, I think stroke is especially amenable to telehealth, since a lot of the exam is observational (hold arms up 10 seconds, hold legs up for 5, face symmetry, aphasia, etc). The challenging part of NIH stroke scale on telehealth is visual fields. That is honestly a crapshoot because you depend on whoever is performing the exam and if they're doing it right (most aren't). That being said, it's not one of the most important parts of the NIH stroke scale so there's that. Sensation is quite subjective to begin with, and also tends to be a crapshoot at times.

Other things such as a segmental strength exam are difficult to grade and perform if you're doing telemedicine for regular hospital consults. I'd guess that's quite hard, as is reflexes because you'd need someone to do it and grade them for you. Perhaps other folks here who do telemed for consults might be able to chime in.

Pupillary light reflex....I don't think I've ever examined that during telemedicine and on most patients it's not worth doing unless it's a suspicion of a massive stroke (usually a bleed or herniation) or if the complaint is ocular in nature (testing for an RAPD).

Hope this helps.

 

[tulsajoe94]

Thank you, I really appreciate this. Visual field testing is certainly an interesting one to think about. One thing we are realizing is telehealth devices patients would keep in their home would be for chronic conditions or rehab. All other “acute” tools need to work on a smart phone or computer.


If you, or anyone else, has a moment to spare, are there tests (for any condition) that are reassessed on multiple follow-ups that may be difficult?

We’re probably mostly looking to make something people in very rural areas or with physical limitations getting to recurring outpatient appointments could keep at home!

 

[deathmerchant]

Hello!

I'm a MS1 in a biomed device/software design class focused on telehealth. I was wondering what tests neurologists do often but are finding difficult to do over telehealth.

For example, do you test the pupillary light reflex often? Or need to assess strength or sensation often?

Thanks for any feedback you can give! We're working w/ PM&R Docs now but know there is sometimes overlap here 🙂

I think the eye exam, esp pupillary reflex is a very important part of neuro exam that is hard to do with current tele health and something that can be done. Although there are many tele-robots that are able to do that. Being able to do a dementia screening might help too (MMSE/MOCA).
I think, It would be hard to examine other things.

 

[JumpingLumberjacksofMaine]

Interesting idea!

I just switched to teleneurology.

Here's what I have thought about:
--Neurovestibular disorders are tough to do (even in-person--it's a real skill) and essentially impossible to do well w/ telemedicine--gross ataxia/coordination (finger to nose, heel to shin) sure, but it's very helpful to look for:

1) Signs of nystagmus
2) Response to Dix-hall-pike, head impulse test, dynamic visual acuity
3) Cover/uncover testing to look for subtle ocular misalignment/skew deviation (at best, I will satisfy myself with the Hirschberg test)
4) Evidence of anisocoria to look for Horner's

Neuro-ophtho relies on a lot of the above tests as well, and also fundoscopy, which is essentially impossible via teleneurology.

There are some solutions to the above for in-person exams (again, these findings are subtle enough that there is some appeal to having something automated/objective/quantitative). There are pupillometers (one neuro-ICU I was at had them); there is one company that I know of (probably more) was trying to develop something for assisting with testing eye movements/nystagmus (an automated "HINTS" tester), there is non-dilated fundoscopic photography (this used an attachment to an ophthalmoscopic to allow a cell phone to take pictures). For whatever reason--probably cost, a feeling that current subjective exam is "good enough", I don't think any of these ever took off. Still, you could imagine these being offered as add-ons with a teleneuro cart.

Happy to share thoughts re: more outpatient type stuff--neuromuscular (quantitative strength assessment), movement disorders etc--though it's hard to imagine these being widely adopted (most of the time you have to see patients with any neuromuscular, movement disorder type condition in-person, with tele-neuro probably being used mainly for quick check-ins).

 

[neglect]

I just switched to teleneurology.

Great name. It was a mass conversion disorder, right?

Just changed to telemed as well (Bob, is that you?). Couple of thoughts.

First of all, the history is very different than in the office. Personally I would never advise my friends or family to do anything over telemed (unless pandemic or other emergency) for this reason alone. Or fine if the problem is "I have a runny nose for the past 2 days." Face to face is just vastly different.

All patients hold information back (ie., they might think disclosing the actual onset makes them appear stupid). This is amplified over telemed. Spouses cannot be honest when their partner is in the room. The office setting forces a level of candor that you don't see when they are in their kitchen. And you can't part ways with the patient to directly interview the spouse, so you're stuck.

So without a crisp, solid history, the exam is useless. You can see overt problems on the level of the NIHSS, and telemed has been very well validated for NIHSS with obvious exceptions above.

I'm doing it, but I consider these consults to be special cases where verification of basic information has to happen when we're through.

The other aspect of this @tulsajoe94 is that all the HIPPA nonsense is waived during the crisis. So we can use Facetime and off the shelf video conferencing, call it telemed (which it is). You're not going to develop a better system than the ones on the market already. They're so many, the saturation is complete IMO. But if this is just an academic project, then fine. Hopefully you'll learn something and be able to apply it to something else.

 

[tulsajoe94]

Yes, right now it is a purely academic project. We went with a plan to make a fairly simple device to compare strength between L+R side and the same side over time (hopefully). Might be useful in physical therapy or some kind of degenerative disorder? The physician we are working with does peds PM&R and said he would have a use for it from time to time.

This did give me a lot to think about though (and a lot to learn about, I didn't know half of the tests @JumpingLumberjacksofMaine mentioned).

My current thoughts are:
- an accurate sensation tool could definitely exist, but not sure it would have a long term use aka no market.
- re: MOCA, there definitely should be ways to get MOCA on a smartphone or computer, though it might be easier to just make a printable form for the patient w/ the visuospatial/execute and naming components (what is the limitation with this @deathmerchant ? I could draw this up if it is useful to you!).
- Would be fascinating to see if drawing with touchpad or mouse provides the same results if this isn't already done!

All the other tests seem like true challenges for people above my negative paygrade 😛

 

[JumpingLumberjacksofMaine]

Re: Neglect--supposedly, but since it was 100+ years ago I guess we'll never know! Not Bob BTW.

Sorry for the logorrhea above--something I've thought about--not so much stuff that would be overly market friendly--but it's this way with a lot of neuro stuff (e.g., automated cognitive testing, quantitative sensory testing may provide mild clinical benefit, but won't increase the wRVU/billing divided by time spent ratio significantly, so won't get adopted--just the truth there). I was mainly thinking more along the lines of if tele-neuro becomes a more entrenched part of care vs mainly for tele-stroke.

Good luck with your project!