We keenly read the publication by Fasano et al., 1 providing deep insight into the management of advanced therapies in Parkinson's disease (PD) patients in times of COVID‐19. We extend the focus to dystonia by sharing our pre‐COVID‐19 experience of using synchronous telemedicine (TM) platform to aid in the initial deep brain stimulation (DBS) programming in 2 dystonia patients. DBS is an effective therapy for dystonia, and globus pallidus interna (GPi) is the primarily used target. Unlike PD programming, clinical benefit in dystonia is noted after prolonged stimulation. 2 Accordingly, at our center, the clinical effect of monopolar stimulation at each contact (unilateral or bilateral parallel axial level contacts for bilateral implants) is evaluated after 1 week. After 4 weeks, patients are placed on the program with the best clinical response, and further stimulation adjustments (SA) are made as needed during routine follow up. This initial programming requires frequent office visits, which may be inconvenient and limiting for patients.
A 73‐year‐old woman with generalized dystonia underwent bilateral GPi DBS, and a 75‐year‐old man with Meige syndrome with bilateral GPi DBS underwent replacement of his left electrode due to capsular side effects. Abbott's Infinity™ and Medtronic DBS system were implanted, respectively. After determining the therapeutic window of each contact during the initial in‐person programming, 4 programs (1 for each contact in a monopolar configuration) were saved, and patients were sent home on the first program. Parameters were set to allow patients to adjust voltage and switch between programs via the patient controller (PC). Subsequent 3 weekly TM visits were scheduled. During each TM visit, patients were evaluated based on subjective reports and clinical examinations. After each week's assessment, patients switched to the next program, which was confirmed visually on the PC. The final program was selected after 4 weeks. There were no failed visits, and both patients expressed satisfaction with TM use.
Despite the increasing use of TM for movement disorders, there is still limited published literature on its use in patients with DBS. 3 Although being explored, one of the challenges is the inability to perform remote programming. 4 However, with proper patient and caregiver education, the physician can allow some programming autonomy through the use of PC. Jitkritsadakul et al. 5 used TM for managing DBS in 49 PD patients, most commonly for post‐DBS assessments. SA via PC were made during 47% of visits either by the patient, caregiver, or local health staff. Similar to Bally et al., 6 we used patient made SA for initial optimal program selection for dystonia but also used TM for clinical exams to aid in decision‐making.
Resuming from the impact of COVID‐19, the surgical practices are beginning to reopen elective DBS cases slowly. However, there is still an emphasis on limiting in‐person visits when feasible, and there is a concern that a second wave may again disrupt in‐person ambulatory visits. Our cases, in line with the previous data, highlight the feasibility of TM for DBS management. Additionally, we highlight its use for managing the initial programming process for DBS in dystonia. With the growing use of DBS, the feasibility of remote programming and alternative healthcare delivery methods need to be further explored.
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.
N.P.: 1A, 1B, 1C, 3A
C.Z.: 1A, 1B, 3B
Disclosures
Ethical Compliance Statement
Institutional review board approval was not required for this observation. Informed patient consent was not necessary for this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.
Funding Sources and Conflict of Interest
No specific funding was received for this work. N.P. has no disclosures to make. C.Z. is employed by Abbvie Inc.
Financial Disclosures for the Previous 12 Months
N.P. has no disclosures to make. C.Z. is employed by Abbvie Inc.
References
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