Movement Disorders in the World of COVID‐19

In a few weeks, our world has become a very different place. Those things that we took for granted have been severely disrupted, and, suddenly, we all fear for our own mortality and health of our loved ones. For those involved in patient care, there are additional challenges. Fortunately, there is to date no evidence that our movement disorders patients are at increased risk of coronavirus infection, compared to individuals of comparable age and with similar comorbidities. Nevertheless, patients with chronic neurological disease are, in general, more susceptible to the effects of serious infection of any kind, perhaps particularly respiratory illness, and even more so if this is compounded by involvement of central respiratory centers, as may be the case for SARS-CoV-2. Emerging guidelines on access to intensive unit care and mechanical ventilation in some countries are excluding access to patients with “very advanced neurological disease. ” This is clearly a fine line to walk that is ethically challenging, but may nonetheless be necessary if limited resources mean that access to advanced care is not available to all. At this point, there is no justification to impose a blanket restriction on patients with Parkinson’s disease (PD), but difficult decisions may need to be made on an individual basis. From a practical perspective, the more widespread challenge is that of providing adequate ongoing care for our patients in the face of the critically necessary self-isolation and social distancing precautions that are now enforced on a virtually global level. In developed countries and for patients with adequate resources, there has been widespread and rapid adoption of telehealth technology that should have perhaps been considered and more widely embraced some time ago. However, we need to remain cognizant that video assessments, though highly practical and validated for certain aspects of the examination, are not the same as an in-person encounter, and not all patients have access to, or comfort in using, the necessary technology. There may also be some concerns on the medico-legal front, but one hopes that pragmatism will prevail in these extraordinary times. On the other hand, video conferencing with a patient and their family members in their home environment may allow insights into their daily lives that we do not enjoy in a standard office/clinic visit. If direct patient contact visits are deemed necessary and urgent, precautions should be taken, including the use of personal protective equipment, but also risk mitigation to minimize exposure of other patients and health care workers. While the number of situations requiring direct patient contact should presumably be limited in our field, one example would be DBS battery failure, which could be life threatening. Although botulinum toxin treatment is currently on hold in most centers, this may ultimately need to be reintroduced on a carefully considered basis for those patients who are suffering from pain or disability. Video-conferencing technology may be helpful not only for physician assessments, but may also permit interaction of allied health personnel either concurrent with or separate from the clinical assessment. Although not permitting the traditional laying on of hands, our patients may still be granted access to counseling, medication advice, and instruction in exercise programs. One of the important practical lessons we have learned from COVID-19 is our need for social interaction, which we take for granted. This is an important therapeutic need for our patients and also for our own health. Although we are no longer able to conduct business as usual, the enforced time at home may allow us to connect with friends and family at a distance, using the same Internet-based video technology. An additional challenge is the high rate at which we are bombarded with new information and updated guidelines and regulations, even from credible sources, to say nothing of the profusion of misinformation for which there is no good scientific basis. For centers that have already established PD registries, obtaining information on the impact of COVID-19 may be feasible and useful. However, the establishment of a new registry could be time-consuming and