Essential Tips for Videotaping a Movement Disorders Patient Encounter

The field of movement disorders relies more heavily on visual observation of phenomenology for diagnosis than most other fields of medicine, including other areas of neurology. The videotaped patient encounter has been used by movement disorder specialists as a learning tool since the field was founded, and in recent years it has become common practice to see videotaped patient encounters added to scientific articles. Some clinical trials incorporate “blinded” reviewers of videotapes to assess efficacy of the drug or surgical procedure being studied. The International Parkinson and Movement Disorder Society holds a “Video Challenge” session at its annual Congress, reflecting the importance of this method as a learning tool and a way of sharing knowledge. The digitization of visual media and ubiquity of smartphones and tablets have greatly simplified the process of videotaping patient encounters, as well as storing and sharing videos. In recent years, video recording using cell phone cameras is becoming more common, particularly among younger physicians. A video recording of a patient encounter adds invaluable information that goes beyond the traditional history and physical examination provided by the written medical record. Similar to the written record, the video record of a patient may aid in the diagnosis, monitoring of disease progression, or may be used for research or educational purposes.1 A videotaped patient encounter also enables the treating provider to consult with colleagues on challenging (difficult) cases, allowing the patient to be “examined” long distance by specialists.

As the world population ages and the prevalence of Parkinson's disease (PD) is expected to rise in the coming years,2 the need for movement disorder specialists will increase. This increased demand may be difficult to meet through local providers alone, and may promote the implementation of remote patient encounters (telemedicine), with the provider based in a movement disorder specialty center. Teleneurology provides neurological expertise to rural areas with limited availability of neurologists and improves care for patients with difficulty traveling owing to neurological disease. Given that the use of teleneurology is expected to increase even more in the coming years,3, 4 the need for standardized, high‐quality, comprehensive videotapes of patients with movement disorders will rise. In our experience, the quality of videos varies widely among clinicians. If obtained without attention to technique, the video can obscure important clinical findings and can even lead to diagnostic errors. However, following a few simple guidelines can maximize the quality of videos. As far as we know, there is only one publication in the literature proposing guidelines for producing a high‐quality videotape patient encounter.5 However, it was geared toward a nursing audience, rather than movement disorders specialists, and written before the advent of digital technology. This is rather surprising given how common a diagnostic and pedagogical tool videotaping is for movement disorder specialists. The following guidelines were devised based on our collective experience from a large movement disorders academic center. They are intended primarily for movement disorder specialists, but many recommendations can be shared with other physicians wishing to consult regarding challenging cases, and even with patients who might be instructed to take videos of themselves at home to document phenomenology not observed in the office or to provide long‐distance follow‐up status.

Technical Considerations

For medicolegal purposes, before videotaping a patient exam, written informed consent must be obtained from the patient.6 The physician should keep this consent together with all other medical documents. We find it preferable to videotape the signed consent form so that it is located directly with the patient's examination on the same video. Written informed consent is also important for facilitating sharing of the videotape with other providers, if needed. All relevant documents should be videotaped, such as the Montreal Cognitive Assessment, handwriting, and Archimedes spiral drawing, given that these tests frequently add valuable information regarding the diagnosis. Ideally, the videotape should be systematic and follow a consistent pattern. Though every physician will have his own style of examining the patient, we have found it works best to first videotape the patient while sitting, and then proceed in the examination in a rostral‐caudal sequence, comparing the two sides after each exam maneuver. This is followed by having the patient arise from a sitting to a standing position (initially without pushing off, if the patient is able, and then pushing off with his or her hands if the patient fails to arise initially). The patient is then asked to walk for at least 5 meters in each direction in an unimpeded corridor with at least two turns to assess gait and turning. Walking is best observed by videotaping the patient walking away from and toward the camera, such that both arms and legs are visible at all times, rather than in a plane 90 degrees from the camera, from which one cannot observe the two sides of the patient's body at the same time. Postural reflexes are assessed with the pull test, which is often abnormal in classical parkinsonism, but may also be helpful in distinguishing between other movement disorders. For example, patients with Huntington's disease, dopa‐responsive dystonia, and MSA frequently have positive pull tests, in contrast to patients with other forms of chorea, dystonia, and cerebellar ataxia, which do not affect postural stability. During the pull test or gait assessment, posture may be recorded as well. After these standing procedures, it is useful to observe the patient in the act of sitting down. This concludes the standard videotape. If clinically indicated, additional videotaping can be done to demonstrate the effect of postures or positions (e.g., lying supine) or specific tasks such as writing, talking, singing, biting, chewing, swallowing, drinking, holding objects, pouring water into a cup, running, tandem walking, walking backward, or standing on one leg.

In almost all circumstances, the videotape can be performed with the patient fully clothed. In specific cases, it may be necessary to remove specific items of clothing obstructing anatomical locations of interest, as in, for example, foot dystonia or spinal myoclonus. The videotape is not uniform for all patients, although the general guidelines do apply to all cases. Different symptoms require focusing on specific tasks.

While videotaping a patient, the camera should be placed directly in front of the patient (rather than off to one side) in order to observe for asymmetries between the two sides of the body. Any objects impairing the camera's view should be removed and care should be taken to avoid videotaping bystanders or family and friends accompanying the patient. The room should be well lit and be large enough to include the patient's entire body within the camera screen. Avoid backlighting by not aiming the camera toward windows or lamps. The background noise (air conditioners and fans) should be minimized in order not to miss relevant clinical signs, such as slurred speech or voice tremor. The photographer should alternately zoom in on the area of interest being examined and zoom out to show the whole body during motor activation. This can sometimes enhance involuntary movements in other parts of the body,7, 8 or cause the disappearance of movements by distraction as occasionally observed in patients with psychogenic movement disorders.9 The patient should sit with arms and legs uncrossed (hands in lap). The camera battery should be fully charged before beginning to videotape in order to maintain continuity of the exam. We recommend videotaping the patient at the first clinic visit in order to have a baseline audiovisual record with which to compare future clinical evaluations. Preferably, the camera operator is not simultaneously examining the patient given that some features of the exam may not be videotaped by the examiner. In the remainder of this article, we offer specific recommendations for videotaping an examination tailored to several common movement disorders.

Parkinsonism

1. Cranial evaluation: Videotape the eyes by zooming in, assessing for square wave jerks, ocular movements, and apraxia of eyelid opening. Videotape the patient speaking to assess for dysarthria and prosody of speech as well as voice amplitude. Videotape the examination of frontal release signs (glabellar, snout, and palmomental signs). While examining for palmomental reflexes, videotape both the hand and face simultaneously (see Videos 1 and 2).

2. When examining hands for re‐emergent tremor, make sure to videotape the hands for at least 15 seconds since this tremor does not appear immediately.10

3. During the pull test, the patient should stand sideways (profile view) relative to the camera. The patient's entire body from head to toe should be viewable so that both the upper and lower body can be observed.

4. Handwriting should be videotaped. It is recommended that the patient write in print as well as script, and write a sentence a minimum of three times, each below the previous one, in order to assess for micrographia and decrement in script size.11

5. Dyskinesias are often enhanced by motor activation including speaking. While examining head or limb movement, be sure to videotape the entire body.

Dystonia

1. When videotaping a patient with cervical dystonia, be sure to include the primary head position and range of neck movement. In addition, videotape the involved muscles which may be hypertrophied. Always ask the patient to lean the back of his or her head against the wall, and videotape any effect on dystonic posture. Have the patient slowly move his or her head in all directions, looking for both null and activating positions. With the head away from the wall, instruct the patient to close his eyes and relax and let the head move by itself if it wants to drift.

2. For task‐specific writer's cramp, include the entire arm in the video, not just the hand. Place the camera so that it is aligned with the patient's forearm. This provides the best view to observe abnormal movements of the forearm. Writing with each hand should be tested. At times during writing, have the camera focus on the nonwriting hand, looking for mirror movements.

3. Videotape handwriting and penmanship even if the patient presents with dystonia in other parts of the body (such as the neck or face) given that the hand is occasionally involved as well.

4. Be sure to remove clothing when videotaping truncal or foot dystonia.

5. If dystonia is observed in any body part, videotape the presence of sensory tricks (gestes antagoniste) and also the testing for null positions.

Essential Tremor

1. Handwriting should be videotaped because this can demonstrate the impact of tremor on writing and also help differentiate between PD (micrographia) and essential tremor (macrographia).12 Archimedes spiral drawing is routinely used to evaluate tremor and should be videotaped in all patients.

2. The patient should be videotaped with hands at rest, assuming a posture, and with action. Postural tremor should be videotaped with the arms stretched in front of the body and in the wing position as well. When videotaping the finger‐to‐nose test, have the camera directly in front of the outstretched arm rather than at a side view.

3. Specific tasks meant to elicit tremor, such as eating with a spoon, pouring liquid from one glass to another, or pointing to a target with a laser pointer, may be useful in the examination and should be recorded.

4. Finger‐to‐nose testing can be cumbersome if the camera operator is also the examiner. In this case, an alternate far target, such as a pen held by the examiner, may be used to extend the distance between the camera and the patient.

Tourette's and Tic Disorders

1. Tics are intermittent in nature, and many patients display fewer in the doctor's office. Therefore, it is important to have the camera running at all times. Once video consent is obtained, set the camera on the desk focused on the patient while the physician is conducting the interview and examining the patient. This extra footage may pick up tics that are not observed otherwise, and noninformative footage may be edited out later. If tics are not observed during the interview or formal examination, leave the camera on the desk running while the examiner excuses him‐ or herself and leaves the room for at least 5 minutes. Often, after the examiner is out of the room, the tics emerge.

2. Because the body part(s) involved in tic disorders may not be immediately apparent to the patient or physician, it is important that the patient's entire body be included in the video. When the location of the tics is identified, close‐ups of these areas can be obtained.

3. Patients should be observed for tics when: speaking, sitting quietly, performing a cognitive task, and walking. During this portion of the examination, they should be instructed to feel free to tic as much or as little as needed. In order to demonstrate the voluntary suppressibility and subsequent rebound of tics, patients should be asked to refrain from exhibiting any motor and vocal tics for a period of at least 30 seconds and then allowed to tic freely.

4. To adequately capture vocal tics, which may be low‐volume sniffing or throat clearing, ensure that the camera's microphone is close enough to the patient and of high enough quality to record these sounds.

Discussion

Videotaping the neurological examination is a valuable diagnostic, educational, and research tool and is especially important in the field of movement disorders, which relies heavily on critical observation of phenomenology. Many videotapes suffer from poor attention to technical issues, which can detract from the quality of the video both by obscuring as well as failing to highlight important clinical information. We hope that the tips for producing an effective video that we have outlined above will serve as a useful guide for clinicians, students, and educators and enhance the effectiveness of the videotaped patient encounter for diverse purposes.

Author Roles

(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique.

D.R.: 1A, 1B, 1C, 3A, 3B

S.F.: 1B, 1C, 3B

M.K.: 1A, 1B, 1C, 3A, 3B

Disclosures

Funding Sources and Conflicts of Interest: The authors report no sources of funding and no conflicts of interest.

Financial Disclosures for previous 12 months: The authors declare that there are no disclosures to report.

Supporting information

Videos accompanying this article are available in the supporting information here.

Video 1. A patient with PD is examined in the sitting position for frontal release signs, eye movements, speech, tongue movements, shoulder shrug, tremor, repetitive movements, and muscle tone.

Video 2. Gait, balance, and writing are examined in the same patient as in Video 1.