For many patients, the expansion of telemedicine may be one of the few good things to come out of the COVID-19 pandemic. But it presents some unique challenges for neurologists.

The sensorimotor exam, for example, can be very difficult to do online.

At the recent fall meeting of the American Academy of Neurology, Dr. Scott Grossman, of NYU Langone Health, shared some tips and tricks to get the most out of this part of a telehealth neuro exam.

A lot can still be gleaned from observing gross movements, posture against gravity, symmetry of movement and drift during a virtual exam, Grossman said. He suggested having patients (who are able) perform push-ups, sit to stand from a chair, and walk on their heels and toes. Patients can even perform a Romberg test, standing in a corner for safety.

The virtual sensorimotor exam is ideally done with the help of an assistant, like a family member. However, this is often not possible because of the social isolation necessary to stay safe during the pandemic.

For this reason, neurologists will often have to rely on patient self-testing, Grossman said.

That is why preparation is key. Instructing patients to be ready for the visit is especially important, he said.

At NYU, they developed varying templates to send out to patients before televisits, including instructions and lists of items to have ready. For the neurology exam specifically, items might include graph paper, an Amsler grid for vision testing, penlight, pen, rubber band, hand weight, tissue or cotton swab, or a cold metal spoon.

What about the more hands-on assessments like manual muscle testing, reflexes and sensation testing? These too can be adapted to the virtual exam, to a degree.

In his talk, Grossman showed video demonstrations of several self-testing measures, including:

  • Using the first and second finger of one hand to resist abduction of the fingers of the other hand.
  • Using the opposite hand to resist elbow flexion and extension of the other arm.
  • Spreading fingers against the resistance of a rubber band.
  • Using finger tapping, pen, or kitchen spatula to self-test deep tendon reflexes and plantar response.
  • Using tissue, cotton swab, cold spoon, or toothpick to self-test sensation types.
  • Rubbing fingers together to self-test hearing.

In addition to observing behavior and movement, the demonstrator in these examples asked the patient if it felt as if one side was harder or easier to perform tasks or felt different than the other.

More examples can be found in a recently published paper in Neurology.

Obviously, this type of self-testing does not fully compare with an actual hands-on neuro exam, Grossman said. It is, however, progress toward meeting the demands of this new clinical environment.

“As we know, there is a shortage of neurologists and this is a way for us neurologists in the community, neurologists in academic medicine, to be more available to patients and to increase the volume of patients that we’re able to see,” Grossman said.

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