# EFAS/EAN survey on the influence of the COVID-19 pandemic on European clinical autonomic education and research

Alessandra Fanciulli, Magdalena Krbot Skorić, Fabian Leys, Diogo Reis

Carneiro, Nicole Campese, Giovanna Calandra-Buonaura, Jennifer

Camaradou, Giacomo Chiaro, Pietro Cortelli, Cristian Falup-Pecurariu, et al.

► To cite this version:

Alessandra Fanciulli, Magdalena Krbot Skorić, Fabian Leys, Diogo Reis Carneiro, Nicole Campese, et al.. EFAS/EAN survey on the influence of the COVID-19 pandemic on European clinical autonomic education and research. Clinical Autonomic Research, 2023, 33 (6), pp.777-790. 10.1007/s10286-023-00985-3. http://hal-04812187

HAL Id: hal-04812187

https://hal.science/hal-04812187v1

Submitted on 18 Feb 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
# EFAS/EAN survey on the influence of the COVID-19 pandemic on European clinical autonomic education and research

Alessandra Fanciulli¹☐, Magdalena Krbot Skoric²,³, Fabian Leys¹, Diogo Reis Carneiro⁴,⁵, Nicole Campese¹,

Giovanna Calandra-Buonaura⁶,⁷, Jennifer Camaradou⁸,⁹, Giacomo Chiaro¹⁰,¹¹, Pietro Cortelli⁶,⁷.

Cristian Falup-Pecurariu¹², Roberta Granata¹, Pietro Guaraldi⁶, Raimund Helbok¹,¹³, Max J. Hilz¹⁴,¹⁵.

Valeria Iodice¹⁰,¹¹, Jens Jordan¹⁶,¹⁷, Evert C. A. Kaal¹⁸, Anita Kamondi¹⁹,²⁰, Anne Pavy Le Traon²¹, Isabel Rocha²².

Johann Sellner²³,²⁴, Jean Michel Senard²⁵, Astrid Terkelsen²⁶, Gregor K. Wenning¹, Elena Moro²⁷.

Thomas Berger²⁸,²⁹, Roland D. Thijs³⁰,³¹, Walter Struhal³², Mario Habek²,³³, the Collaborators of European Network of Neurological Autonomic Laboratories

Received: 14 July 2023 / Accepted: 11 September 2023 / Published online: 4 October 2023
© The Author(s) 2023

## Abstract

**Purpose** To understand the influence of the coronavirus disease 2019 (COVID-19) pandemic on clinical autonomic education and research in Europe.

**Methods** We invited 84 European autonomic centers to complete an online survey, recorded the pre-pandemic-to-pandemic percentage of junior participants in the annual congresses of the European Federation of Autonomic Societies (EFAS) and European Academy of Neurology (EAN) and the pre-pandemic-to-pandemic number of PubMed publications on neurological disorders.

**Results** Forty-six centers answered the survey (55%). Twenty-nine centers were involved in clinical autonomic education and experienced pandemic-related didactic interruptions for 9 (5; 9) months. Ninety percent (n = 26/29) of autonomic educational centers reported a negative impact of the COVID-19 pandemic on education quality, and 93% (n = 27/29) established e-learning models. Both the 2020 joint EAN-EFAS virtual congress and the 2021 (virtual) and 2022 (hybrid) EFAS and EAN congresses marked higher percentages of junior participants than in 2019. Forty-one respondents (89%) were autonomic researchers, and 29 of them reported pandemic-related trial interruptions for 5 (2; 9) months. Since the pandemic began, almost half of the respondents had less time for scientific writing. Likewise, the number of PubMed publications on autonomic topics showed the smallest increase compared with other neurological fields in 2020–2021 and the highest drop in 2022. Autonomic research centers that amended their trial protocols for telemedicine (38%, n = 16/41) maintained higher clinical caseloads during the first pandemic year.

**Conclusions** The COVID-19 pandemic had a substantial negative impact on European clinical autonomic education and research. At the same time, it promoted digitalization, favoring more equitable access to autonomic education and improved trial design.

**Keywords** COVID-19 pandemic · Autonomic nervous system · Clinical autonomic education · Clinical autonomic research · e-Learning · Telemedicine

## Introduction

With the rise of herd immunity, four years into the coronavirus disease 2019 (COVID-19) pandemic, diminishing numbers of newly diagnosed COVID-19 cases and deaths are registered worldwide [36]. Notwithstanding, the COVID-19 pandemic brought major changes to our society and healthcare systems, the consequences of which are still being dealt

<footnote>The Collaborators of European Network of Neurological Autonomic Laboratories mentioned in “Acknowledgements” section.</footnote>

<footnote>Extended author information available on the last page of the article</footnote>
with. Beyond the global drug [19] and medical device short-
ages [29], supply chain disruptions [6, 35], and increased
healthcare workers' burden [18, 22, 26], the COVID-19
pandemic directly affected clinical neurological practice in
multiple ways. In the field of autonomic nervous system dis-
orders, many referral centers were forced throughout Europe
to stop their activities due to pandemic containment meas-
ures, with major consequences on the quality and continu-
ity of autonomic healthcare provision [4, 12]. On the other
hand, both COVID-19 and, to a lesser extent, COVID-19
vaccines were reportedly associated with new diagnoses or
significant worsening of previously diagnosed cardiovascu-
lar autonomic disorders, increasing the number of individu-
als requiring specialized autonomic care [12, 13, 30].

Studies among neurology trainees and teachers high-
lighted how the COVID-19 pandemic negatively influenced
not only clinical practice, but also bedside learning and
training of neurological skills [9, 15, 32]. Likewise, the
pandemic outbreak severely impacted neurological research,
with several non-COVID-19-related clinical trials being put
on hold, not initiated at all, or undergoing substantial amend-
ments to mitigate the pandemic-related recruitment losses
and drop-outs [2, 5, 9].

It is however still unknown how and to what extent
the COVID-19 pandemic influenced the educational and
research activities in neurology subspecialties with limited
availability of referral centers across European countries,
such as the autonomic field. To answer this question, the
European Federation of Autonomic Societies (EFAS) and
the Scientific Panel for Autonomic Nervous System Dis-
orders of the European Academy of Neurology (EAN)
launched a joint web-based survey among the European
neurological autonomic centers investigating the influence
of the COVID-19 pandemic on clinical autonomic education
and research.

**Methods**

Survey participants

A comprehensive description of the survey methodology
has been previously published [16]. Briefly, we invited all
the directors of neurology-driven and interdisciplinary (i.e.,
with at least one neurologist in the core team) European
autonomic centers to complete a web-based survey between
September and November 2021. Up to three reminders were
sent to nonrespondents prior to the survey closure.

Questionnaire

The questionnaire covered the following topics (see full text
in the Supplementary Material):

* Demographic information of the survey respondents and characteristics of the autonomic center, including equipment, staff and pre-pandemic-to-pandemic caseload;

* Influence of the COVID-19 pandemic on autonomic educational activities and lessons learned for an improved autonomic educational offer;

* Influence of the COVID-19 pandemic on clinical autonomic research, time availability for scientific writing, and lessons learned for an optimized autonomic research practice.

COVID-19 pre-pandemic-to-pandemic proportion
of junior participants in international neurological
congresses

To understand the effect of in-person versus virtual or hybrid congress formats on the proportion of junior participants attending the annual general neurology (i.e., EAN) and autonomic subspecialty congresses (i.e., EFAS), we asked the EAN head office and the organizers of the 2019–2022 EFAS congresses about the overall number of congress participants and registered junior participants (residents, research fellows, and undergraduate students).

COVID-19 pre-pandemic-to-pandemic publication
output in different neurological subspecialties

For comparison purposes, we searched the PubMed data-
base for the 2017–2022 number of publications/year on
autonomic versus other main neurological disorders and
subspecialties using the search terms reported in the Sup-
plementary Material. The count included all types of manu-
scripts without language restrictions. The annual percentage
change in the number of publications was plotted separately
for each neurology subspecialty for visual comparison.

**Statistical analysis**

Qualitative variables were summarized in frequencies (per-
centages) and compared using the chi-square or Fisher exact
test. Quantitative variables were summarized in median
values (25th; 75th percentile) or mean ± standard devia-
tion. The Mann–Whitney *U*-test was used for comparing
non-normally distributed quantitative variables, the *t* test for
normally distributed ones. Associations between variables
were tested with the Spearman’s correlation coefficient. All
statistical analyses were performed with IBM-SPSS (version
25). Two-sided *P* values < 0.05 were considered statistically
significant.

Firstly, we performed a descriptive analysis of the char-
acteristics of the survey respondents and autonomic cent-
ers involved in autonomic education compared with those
respondents who were not. We then assessed the influence

<figure><img src="image_2.png" /></figure>
of the COVID-19 pandemic on the availability and quality of clinical autonomic education. Whenever the number of respondents was more than eight per subgroup, we determined whether the respondent or center characteristics, including their geographical localization [16], were significantly associated with any educational outcome measure.

Secondly, we summarized the characteristics of the centers actively involved in clinical autonomic research versus those that were not. Afterwards, we analyzed how the COVID-19 pandemic influenced the research performance of the respondents, including time availability for paper and grant writing. Whenever an adequate sample size was available (i.e., more than eight respondents per subgroup), we determined whether any specific respondent or center characteristic was significantly associated with the reported changes in research practice.

Open-ended questions on lessons learned from the COVID-19 pandemic for an improved autonomic education and research practice were analyzed with a semiquantitative technique.

Thirdly, we documented the pre-pandemic-to-pandemic percentage of junior participants in the annual EAN and EFAS congresses, and the annual percentage change in the number of PubMed publications on autonomic versus other main neurological disorders.

## Data availability statement

The first and the last authors take full responsibility for the integrity of data and agree to share any de-identified data not published herewith upon reasonable request from any qualified investigator.

## Results

### Survey respondents

Forty-six out of 84 (55%) directors of clinical autonomic centers from 22 European countries answered the survey. Detailed information on the respondents and center characteristics has been previously published [16]. Briefly, the respondents and autonomic centers showed homogeneous characteristics across Europe, but their geographical distribution was skewed towards Northern/Western European countries compared with Southern/Eastern European ones [16].

Twenty-nine (63%) survey respondents were reportedly involved in autonomic educational activities, without differences in terms of demographic characteristics, years of clinical practice, or geographical localization with respect to respondents not involved in autonomic education (Table 1). The percentage of autonomic centers closed during the

COVID-19 pandemic and the length of such closures also did not differ between centers that were or were not involved in autonomic education (Table 1). Notwithstanding, centers involved in autonomic education performed a higher number of tilt-table tests (TTT) (p = 0.016) and autonomic outpatient visits (p = 0.034) in the first pandemic year compared with those not involved in educational activities (Table 1).

Most survey respondents were involved in autonomic research (89%, n = 41), mainly focused on autonomic failure in movement disorders, postural orthostatic tachycardia syndrome and reflex syncope (Table 1) [16]. No subgroup comparison was therefore performed.

## Impact of the COVID-19 pandemic on clinical autonomic education in Europe

Since the pandemic outbreak, 93% (n = 27/29) of autonomic centers involved in education were forced to stop in-person teaching for a median of 9 (5; 9) months (Fig. 1). Seventy-six percent (n = 22/29) of centers involved in autonomic education also interrupted internship and practical training programs for 5 (5; 9) months (Fig. 1). In response to the COVID-19 pandemic-related educational barriers, most centers (93%, n = 27/29) switched to e-learning formats (Fig. 2). Notwithstanding, 90% of survey respondents involved in clinical autonomic education agreed that the COVID-19 pandemic had a negative effect on the overall quality of their institutional educational offer; 55% (n = 16/29) judged such effect as moderate to severe (Fig. 1C).

## Lessons learned from the COVID-19 pandemic for an improved clinical autonomic education

Six respondents made suggestions regarding possible strategies to raise the quality of clinical autonomic education in the future. They recommended the integration of online courses and on-demand webinars in medical school curricula and the enrichment of neurology residency programs with rotations in autonomic units, autonomic case-series classes, and in-person or remote autonomic video clinic attendance.

## COVID-19 pre-pandemic-to-pandemic proportion of junior participants in the annual EAN and EFAS congresses

Following the world-wide lockdown in March 2020, the EAN rapidly converted the planned annual congress into a fully virtual event with free registration for all attendees. This was an EAN-EFAS joint congress and marked a substantial increase in the number of registered junior participants (Fig. 3) from European, North American, South American, and Asian countries [33]. In 2021, the EAN and EFAS
<table><caption>**Table 1** Characteristics and COVID-19 pre-pandemic-to-pandemic clinical caseloads of the European autonomic centers involved versus non-involved in clinical autonomic education and research</caption><thead><tr><th rowspan="2">Variable</th><th colspan="3">Clinical autonomic education</th><th colspan="2">Clinical autonomic research</th></tr><tr><th>Involved labs<br>(n=29)</th><th>Non-involved labs<br>(n=17)</th><th>p value</th><th>Involved labs<br>(n=41)</th><th>Non-involved labs<br>(n=5)</th></tr></thead><tbody><tr><td>Head of the laboratory</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female (%)</td><td>9 (31%)</td><td>9 (52.9%)</td><td>0.212</td><td>17 (41.5%)</td><td>1 (20%)</td></tr><tr><td>Age (years)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>30–39</td><td>5 (17.2%)</td><td>3 (17.6%)</td><td>0.689</td><td>8 (19.5%)</td><td>0</td></tr><tr><td>40–49</td><td>15 (51.7%)</td><td>6 (35.3%)</td><td></td><td>20 (48.8%)</td><td>1 (20%)</td></tr><tr><td>50–59</td><td>7 (24.1%)</td><td>7 (41.2%)</td><td></td><td>10 (24.4%)</td><td>4 (80%)</td></tr><tr><td>60–69</td><td>2 (6.9%)</td><td>1 (5.9%)</td><td></td><td>3 (7.3%)</td><td>0</td></tr><tr><td>Years into practice</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Resident</td><td>1 (3.4%)</td><td>1 (5.9%)</td><td>0.235</td><td>2 (4.9%)</td><td>0</td></tr><tr><td>Junior consultant (0–4 years)</td><td>0</td><td>1 (5.9%)</td><td></td><td>1 (2.4%)</td><td>0</td></tr><tr><td>Consultant (5–9 years)</td><td>3 (10.3%)</td><td>1 (5.9%)</td><td></td><td>4 (9.8%)</td><td>0</td></tr><tr><td>Senior consultant (10–19 years)</td><td>13 (44.8%)</td><td>3 (17.6%)</td><td></td><td>15 (36.6%)</td><td>1 (20%)</td></tr><tr><td>> 20 years</td><td>12 (41.4%)</td><td>11 (64.7%)</td><td></td><td>19 (46.3%)</td><td>4 (80%)</td></tr><tr><td>Geographical localization*</td><td>20 (69%):9 (31%)</td><td>10 (59%):7 (41%)</td><td>0.534</td><td>25 (61%):16 (39%)</td><td>5 (100%):0 (0%)</td></tr><tr><td>Cumulative number of staff members</td><td>9 (7–12)</td><td>7 (6–13)</td><td>0.755</td><td>8 (6–12)</td><td>10 (8–24)</td></tr><tr><td>No. of TTT/year before COVID-19</td><td>150 (55; 300)</td><td>50 (42; 175)</td><td>0.06</td><td>120 (50; 252)</td><td>40 (24; 200)</td></tr><tr><td>No. of outpatient visits/year before COVID-19</td><td>220 (150; 400)</td><td>113 (65; 250)</td><td>0.06</td><td>200 (100; 340)</td><td>100 (;)</td></tr><tr><td>No. of inpatient visits/year before COVID-19</td><td>20 (5; 95)</td><td>50 (1; 125)</td><td>0.79</td><td>25 (5; 118)</td><td>4 (;)</td></tr><tr><td>No. of TTT in the 1st pandemic year</td><td><strong>66 (30; 161)</strong></td><td><strong>20 (1; 75)</strong></td><td><strong>0.016</strong></td><td>60 (20; 118)</td><td>15 (5; 145)</td></tr><tr><td>No. of outpatient visits in the 1st pandemic year</td><td><strong>140 (50; 235)</strong></td><td><strong>45 (15; 90)</strong></td><td><strong>0.034</strong></td><td>110 (40; 210)</td><td>80 (;)</td></tr><tr><td>No. of inpatient visits in the 1st pandemic year</td><td>10 (2; 43)</td><td>7 (0; 38)</td><td>0.438</td><td>10 (1; 46)</td><td>3 (;)</td></tr><tr><td>Percentage reduction in TTT/year</td><td>-50% (-67%; -27%)</td><td>-47% (-92%; -20%)</td><td>0.45</td><td>-50% (-75%; -24%)</td><td>-29% (-80%; -10%)</td></tr><tr><td>Percentage reduction in outpatient visits/year</td><td>-43% (-61%; -10%)</td><td>-50% (-72%; -10%)</td><td>0.563</td><td>-50% (-66%; -18%)</td><td>-20% (;)</td></tr><tr><td>Percentage reduction in inpatient visits/year</td><td>-50% (-86%; -14%)</td><td>-56% (-98%; -23%)</td><td>0.41</td><td>-53% (-88%; -20%)</td><td>-35% (;)</td></tr><tr><td>No. of inhabitants in the referral area</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>≤500,000</td><td>6 (20.7%)</td><td>6 (35.3%)</td><td>0.651</td><td>9 (22%)</td><td>3 (60%)</td></tr><tr><td>500,000–1,000,000</td><td>13 (44.8%)</td><td>7 (41.2%)</td><td></td><td>18 (43.9%)</td><td>2 (40%)</td></tr><tr><td>1,000,000–5,000,000</td><td>9 (31%)</td><td>3 (17.6%)</td><td></td><td>12 (29.3%)</td><td>0</td></tr><tr><td>> 5,000,000</td><td>1 (3.4%)</td><td>1 (5.9%)</td><td></td><td>2 (4.9%)</td><td>0</td></tr><tr><td>Closure of TTT labs during the pandemic</td><td>21 (75%)</td><td>10 (58.8%)</td><td>0.326</td><td>29 (72.5%)</td><td>2 (40%)</td></tr><tr><td>Length of closure of the TTT labs, in months</td><td>2 (2; 5)</td><td>5 (4; 9)</td><td>0.072</td><td>5 (2; 9)</td><td>2 (;)</td></tr><tr><td>Closure of outpatient clinics during the pandemic</td><td>17 (60.7%)</td><td>10 (58.8%)</td><td>1</td><td>25 (62.5%)</td><td>2 (40%)</td></tr><tr><td>Length of closure of outpatient clinics, in months</td><td>2 (2; 5)</td><td>5 (2; 9)</td><td>0.486</td><td>5 (2; 9)</td><td>2 (;)</td></tr><tr><td>Closure of inpatient clinics during the pandemic</td><td>12 (42.9%)</td><td>8 (47.1%)</td><td>1</td><td>20 (50%)</td><td>0</td></tr><tr><td>Length of closure of inpatient clinics, in months</td><td>2 (2; 8)</td><td>5 (2; 9)</td><td>0.348</td><td>2 (2; 9)</td><td>—</td></tr></tbody></table>

Comparisons between centers involved and non-involved in clinical autonomic research were not performed due to the low number of centers not involved in research (n=5)

Statistically significant differences are highlighted in bold

No./n, number; TTT, tilt-table tests

*Northern/Western Europe versus Southern/Eastern Europe
**A** During the COVID-19 pandemic, did you have ... ?

<figure><img src="image_3.png" /></figure>

**B** If you had to stop, for how long?

<figure><img src="image_4.png" /></figure>

**C** How much did the COVID-19 pandemic negatively affect your institutional ANS education quality?

<figure><img src="image_5.png" /></figure>

**Fig. 1** Type (A) and length (B) of changes in clinical autonomic educational activities from the beginning of the COVID-19 pandemic in the institutions of the European clinical autonomic centers. C The estimated impact of the COVID-19 pandemic on the overall quality of clinical autonomic education in the opinion of the survey respondents. Centers with in-person lesson stops for more than 6 months had a significantly lower number of TTT (74±81 versus 231±223, *p*=0.037) and autonomic inpatient admissions during the first pandemic year (15±28 versus 45±38, *p*=0.036), as well as longer autonomic function laboratory [5 (4; 9) versus 2 (2; 3) months, *p*=0.013] and outpatient clinic [5 (5; 9) versus 2 (2; 2) months, *p*=0.004] closures. Centers reporting internship training stops for

longer than 6 months had a significantly higher cumulative number of staff members (11±4 versus 7±4, *p*=0.038) and bigger reduction in the number of TTT during the first pandemic year (−57±29% versus −30±25%, *p*=0.027). Participants who reported a moderate to severe negative effect of the COVID-19 pandemic on clinical autonomic education were more frequently from Southern/Eastern European than Northern/Western European countries (89% versus 40%, *p*=0.020), had greater reductions in the number of autonomic outpatient visits during the first pandemic year (−49±25% versus −23±28%) and longer autonomic function laboratory closures [5 (2; 9) versus 2 (2; 3) months, *p*=0.049]

annual congresses were organized in a virtual format, with reduced registration fees for EAN neurology trainees and waved fees for EFAS trainees and EAN/EFAS undergraduate students. Both congresses ultimately achieved higher percentages of registered junior participants than in pre-pandemic years (Fig. 3). Such rising trend was confirmed in 2022, when both the EAN and EFAS opted for a hybrid congress format (Fig. 3).

## Impact of the COVID-19 pandemic on clinical autonomic research in Europe

Since the pandemic onset, 78% of European autonomic centers involved in research activities experienced project delays,

with clinical trial recruitment stops for 5 (2; 9) months (Fig. 4A, B), difficulties in managing multicenter projects (59% of respondents, *n*=23/39), and international scientific exchange programs (35%, *n*=14/40). As a result, 17% (*n*=7/41) of researchers faced financial losses and 9% (*n*=3/33) budgetary runouts. Thirty-eight percent (*n*=15/40) of autonomic researchers were able to amend their study protocols, embedding telemedicine-based visits and study outcome measures (Fig. 4).

When specifically asked about the availability of time to write scientific papers during the first COVID-19 pandemic wave, 46% (*n*=19/41) of autonomic researchers had less time, while 27% (*n*=11/41) had more time than before the pandemic (Fig. 5). During the following waves, the
## Did your institution establish ... ?

<figure><img src="image_6.png" /><figcaption>**Fig. 2** Types of distance learning models established in the institutions of the European clinical autonomic centers involved in autonomic education since the COVID-19 pandemic begin. Other models of distance learning included interactive case presentations</figcaption></figure>

percentage of respondents who had less time than usual for paper writing remained similar (42%, n = 17/41), but the percentage of those who reported to have more time for publishing than usual dropped to 15% (n = 6/41, Fig. 5). Such time constraints were reportedly even more impactful on the preparation of research grant proposals (Fig. 5).

## Lessons learnt from the COVID-19 pandemic for improved clinical autonomic research practice

Eleven respondents shared their opinion on novelty elements and needs raised by the COVID-19 pandemic in autonomic research settings; eight considered the introduction of online meetings a cost- and time-effective strategy for lowering the networking barriers among autonomic centers. Two respondents stressed the importance of securing adequate amounts of research time, financial, and infrastructural support for clinical autonomic research. Three respondents finally highlighted how the COVID-19 pandemic facilitated telemedicine implementation in research protocols, overall adding flexibility to clinical trial design.

## Pre-pandemic-to-pandemic number of PubMed publications on autonomic versus other neurological disorders

Before the pandemic, the number of PubMed publications on autonomic disorders was the lowest among several other major neurological subspecialties (n = 4675, Fig. 6A) but showed comparable annual percentage increases [+1% versus +3% (3%; 5%), Fig. 6B].

In 2020, the annual number of publications increased substantially in all neurology subspecialties [+14% (11%; 15%)]. In the autonomic field, however, the annual percentage increase was substantially lower (+6%) compared with other fields, such as headache (+21%), multiple sclerosis (+15%), or stroke (+15%, Fig. 6B). In 2021, the annual percentage increase in the number of publications attenuated in all neurology subspecialties [+7% (4%; 10%)], including autonomic nervous system disorders (+5%). Except for the dementia field, in 2022, the number of publications diminished by 4% (–2%; –6%) in all neurology fields compared with 2021. This reduction was most prominent for autonomic (–16%) and clinical neurophysiology (–13%) research topics.

## Discussion

This survey highlighted a previously underestimated, substantial impact of the COVID-19 pandemic on clinical autonomic education in Europe.

We found that centers involved in clinical autonomic education maintained higher clinical caseloads than non-involved centers during the first pandemic year. Educational centers were possibly national referral centers enabled to continue working and/or receive referrals from other peripheral centers, which were closed during the lockdown. Among the centers involved in clinical autonomic education, those with longer teaching interruptions were also those with major pandemic-related reductions in the autonomic outpatient and inpatient metrics. This may indicate increased difficulties in controlling the pandemic spread at a local level, or alternatively reflect stricter lockdown policies in some European countries [7, 17, 37].

Respondents from Southern/Eastern European countries pinpointed a more severe pandemic-related autonomic educational gap than those from Northern/Western European countries. Such a gap likely affected trainees of two to three subsequent academic years, who may have been also exposed to increased risks of anxiety, depression, and burnout [11] and now need to close their knowledge gaps with individual efforts. To this end, the survey respondents indicated e-learning educational formats as a useful tool to break down the geographical barriers to clinical autonomic

<figure><img src="image_7.png" /></figure>
<figure><img src="image_8.png" /><figcaption>**Fig. 3** COVID-19 pre-pandemic-to-pandemic number of neurology trainees and undergraduate students participating in the annual congresses of the European Academy of Neurology (EAN) and European Federation of Autonomic Societies (EFAS). The EAN congress program entailed two sessions on autonomic nervous system topics in 2019, five in 2020, three in 2021, and two in 2022</figcaption></figure>

A Due to the COVID-19 pandemic, did you have ... ?

<figure><img src="image_9.png" /></figure>

B If you had to stop clinical trial recruitment, for how long ?

<figure><img src="image_10.png" /><figcaption>**Fig. 4** Impact of the COVID-19 pandemic on clinical autonomic research in Europe (A), including cumulative trial recruitment stop duration (B). Centers reporting trial recruitment stops for more than 6 months had a significantly lower number of autonomic outpatient visits during the first pandemic year [48 (25; 123) versus 125 (85; 274), *p*=0.045] compared with those whose trial recruitment stops lasted 6 months or less. Survey respondents, who amended their</figcaption></figure>

study protocols for telemedicine had a significantly higher number of TTT both in pre-pandemic years [250 (50; 400) versus 100 (47; 195), *p*=0.015] and during the first pandemic year (194±219 versus 63±72, *p*=0.039), as well as higher numbers of autonomic inpatient admissions during the first pandemic year [28 (9; 96) versus 5 (0; 24), *p*=0.022] compared with those who did not implement telemedicine in their research protocols
<figure><img src="image_11.png" /><figcaption>**Fig. 5** Impact of the COVID-19 pandemic on time availability for paper and grant writing in the experience of the survey respondents involved in clinical autonomic research. We found no association between any respondent or autonomic center characteristic and the COVID-19 pre-pandemic-to-pandemic change in time availability for paper writing. Likewise, we observed no difference in the</figcaption></figure>

respondents or center characteristics between respondents reporting increased or diminished time available for grant writing during the first pandemic wave, but respondents reporting less time for grant writing during the following waves belonged to centers with longer autonomic function laboratory closures (6±4 versus 4±3 months, *p*=0.036)

education. Digital educational formats may, in fact, promote more equitable access to education in neurology and its subspecialties, as highlighted by the increasing number of trainees, especially those from lower-income countries participating in the EAN and EFAS annual congresses since the introduction of less expensive virtual formats. At the same time, in-person participation of younger colleagues in international congresses should be actively encouraged with dedicated travel grants, reduced registrations fees, and invitations to give oral presentations to promote their engagement in professional networks [21, 34].

The survey respondents also highlighted multiple inter-
ferences of the COVID-19 pandemic with European auto-
nomic research. Early during the pandemic, lawmakers
may have deemed the risk–benefit ratio of research activi-
ties unfavorable in the short term. The long-term effects of
missed or delayed research progress on healthcare quality
are, however, yet to be quantified, especially considering that
autonomic disturbances may frequently develop or worsen
within the so-called post-COVID-19 condition [12, 25, 30].
To this end, it is concerning that most survey respondents
reported diminished time available for scientific writing
since the pandemic onset, which further decreased during
the following pandemic waves. The fact that many regular
duties had to be carried on with additional COVID-19 safety
constraints possibly raised the overall individual workload to
a critical level. This is mirrored by the number of PubMed

publications on autonomic nervous system disorders, which
showed the least annual percentage increase with respect to
other neurological subspecialties during the first two pan-
demic years and the most pronounced reduction in 2022.
Similar negative trends were observed in other subspecial-
ties relying on elective diagnostic workups, such as clinical
neurophysiology.

In analogy to the autonomic educational outcomes, we
found that centers interrupting their trial recruitment for
longer times also had lower clinical performances during
the first pandemic year. These centers might have been hit
“harder” in terms of local pandemic spread, or staff members
might have suffered severe COVID-19 forms or developed
post-COVID-19 disturbances, diminishing their working
capability for some time. On the other hand, some institu-
tions might have been better able to implement pandemic-
mitigating strategies, as shown by the fact that centers
implementing telemedicine in their research activities also
performed more autonomic assessments and visits during
the first pandemic year.

The pandemic-related healthcare digitalization, thus, pro-
moted resilience not only in clinical autonomic practice [12,
31], but also in research, reshaping clinical trial design in
several ways. Several observational studies—and even parts
of interventional studies—are now often run in a decentral-
ized way, with comparable recruitment rates and degrees
of patient satisfaction [23]. For this purpose, video-based
<caption>**Fig. 6** Cumulative number of publications in a pre-COVID-19 pandemic year (2017) on autonomic nervous system versus other frequent neurological disorders and neurology subspecialties (A). B The COVID-19 pre-pandemic-to-pandemic annual percentage change in the number of publications on autonomic topics (blue line) compared with other main neurological disorders and subspecialties (dotted lines)</caption>

A

<figure><img src="image_12.png" /></figure>

B

<figure><img src="image_13.png" /></figure>

versions of conventional motor rating scales have been
developed [14], eventually highlighting a high intra-indi-
vidual variability in motor performance in home settings,
which would have otherwise remained undetected with tra-
ditional hospital-based assessments [10, 14]. Telemonitoring
tools are being increasingly integrated in clinical studies [1],
further shifting the focus towards rater-independent outcome
measures [27, 28]. Many organizational study meetings are
now also run in a virtual format, reducing organizational
costs. This is particularly important in the setting of rare
autonomic disorders, where lower operational costs may
encourage industry investments.

Research digitalization may also provide other types of
benefits to the scientific community. Faster information
exchange through online meetings fosters multicenter coop-
eration. Lowered need for business traveling has the poten-
tial of promoting individual productivity, work–life balance,
and gender parity, facilitating child and other familial care
duties. The decreased number of both business flights and

patients' travels to study centers may ultimately reduce the
ecological footprint of research activities.

The present study has some limitations. First, the results
are based on the information provided by the survey
respondents, while consulting source data was beyond the
scope of the present work. The survey respondents were,
however, directors of autonomic centers with experienced
insights into the European clinical autonomic landscape. The
additional objective outcome measures considered in the
present study, such as the pre-pandemic-to pandemic num-
ber of junior participants attending international congresses
and the number of scientific publications on autonomic ver-
sus other neurology subspecialty topics, were also aligned
with the respondents' views. Second, our study might have
underestimated the impact of the pandemic on clinical auto-
nomic education and research in regions without available
autonomic centers or in those identified centers that did not
complete the survey despite the reminders sent. In order to
reduce inequity in clinical autonomic education and research
across Europe, both EFAS and the EAN should work on further promoting the inclusion of currently underserved countries and colleagues in their professional network and future initiatives. Third, the keywords used for the PubMed search on the pre-pandemic-to-pandemic number of publications across neurology subspecialties might have missed publications including autonomic outcome measures among the secondary objectives or studies investigating autonomic disturbances in common neurological conditions, such as movement disorders, stroke, or epilepsy, may have been counted multiple times in the PubMed search. To overcome this potential methodological bias, we based our comparative analysis on the annual percentage change in the number of publications per neurology subspecialty. Fourth, we were unable to quantify the monetary impact of the COVID-19 pandemic on academic research funding. Studies in other medical specialties reported pandemic-related financial losses of 13 to 25% [3, 20], and this might have been the case in autonomic settings as well.

In conclusion, while exerting a negative effect on the quality of clinical autonomic education in Europe, the COVID-19 pandemic promoted its digitalization and therefore fruition outside of autonomic referral centers. Likewise, the pandemic had a negative impact on clinical autonomic research and the scientific output of autonomic researchers. Nevertheless, it facilitated telemedicine implementation in clinical autonomic research, lowered the organizational barriers for networking among autonomic centers, and promoted digital literacy even among elderly individuals [24]. Altogether, digital communication tools provide novel educational and scientific opportunities, which the autonomic community should build upon beyond the COVID-19 pandemic horizon while taking into account legal and security aspects, as well as the needs of vulnerable patients with lower education and/or [23] cognitive disability [8].

**Supplementary Information** The online version contains supplementary material available at https://doi.org/10.1007/s10286-023-00985-3.

**Acknowledgements** We would like to thank Ms. Lucia Pavlakova, Ms. Abigail Magno (EAN Scientific Department), Mr. Martin Dunzinger (EAN IT-Coordinator) and Mr. Peter Hofmann (EAN Registration Department) for their excellent administrative support and the following collaborators of the European Network of Neurological Autonomic Laboratories for their thoughtful completion of the survey: Ivan Adamec—Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia; Arnaud Aerts—Department of Cardiology, Zuyderland Medical Centre, Heerlen, Netherlands; Leo LR Canta—Department of Neurology, Catharina Ziekenhuis, Eindhoven, Netherlands; Robert Shane Delamont—Department of Neurology and Clinical Neurophysiology, King’s College Hospital, London, UK; Frederik de Lange—Syncope Unit, Amsterdam University Medical Center, Amsterdam, Netherlands; Francesca Del Sorbo—Parkinson and Movement Disorders Unit, ASST Gaetano Pini-CTO, Milano, Italy; Grazia Devigili—Parkinson and Movement Disorder Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy; Rita Di Leo—Department of Neurology, Ospedale San Giovanni e Paolo,

Venezia, Italy; Trang Dinh—Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands; Jacques-Olivier Fortrat—Explorations Fonctionnelles Vasculaires, Centre Hospitalier Universitaire, Angers, France; Janne Gierthmühlen—Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany; Martin Hemels—Department of Cardiology, Rijnstate Hospital and Radboud University Medical Center, Arnhem—Nijmegen, Netherlands; Julia Köhn—Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany; Thomas Kroigård—Department of Neurology, Odense University Hospital, Odense, Denmark; Axel Lipp—Department of Neurology, Park-Klinik Weißensee, Berlin, Germany; Andrea Maier—Department of Neurology, Outpatient Service for ANS Disorders, University Clinic RWTH Aachen, Aachen, Germany; Lucio Marinelli—Department of Neuroscience, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Anna Mazzeo—Department of Clinical and Experimental Medicine, Neurology and Neuromuscular Disease Unit, Messina, Italy; Ivan Milenkovic—Department of Neurology, Medical University of Vienna, Vienna, Austria; Maciej Motyl—Department of Neurology, Jagiellonian University Medical College, Krakow, Poland; Maria Grazia Natali Sora—Department of Neurology, Ospedale San Raffaele, Milano, Italy; Judith Navarro-Otano—Department of Neurology, Hospital Clinic, Barcelona, Spain; Kristian Bernhard Nilsen—Department of Neurology, Oslo University Hospital, Oslo University Hospital, Norway; Mario Oliveira—Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal; Petter Moe Omland—Department of Neurology, Section of Clinical Neurophysiology, St. Olaversus University Hospital, Trondheim, Norway; Giuseppe Pelliccioni—Department of Neurology, Istituto Nazionale di Ricovero e Cura per Anziani IRCCS Ancona, Ancona, Italy; Yann Pereon—Reference Centre from Neuromuscular Disorders, Department of Neurology, University Hospital, Nantes, France; Roland Josef Resch—Department of Neurology, Kepler University, Linz, Austria; Camilla Rocchi—Department of Neurology, Policlinico Tor Vergata, University of Rome “Tor Vergata”, Rome, Italy; Frederic Roche—Department of Clinical Physiology, CHU And INSERM U 1059 Sainbiose, Saint Étienne, France; Joost Rutten—Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Beatriz Tijero-Merino—Movement Disorders and Autonomic Disorders Unit, Cruces Hospital, Barakaldo, Spain; Marcin Tutaj—Department of Neurology, Jagiellonian University Medical College, Krakow, Poland; A. M. H. G. van der Heijden-Montfroy—Department of Neurology, VieCuri, Venlo, Netherlands; Bas JA van Hoeve—Department of Neurology, ZorgSaam Hospital, Terneuzen, Netherlands; Narender van Orshoven—Department of Neurology, Zuyderland Medical Centre, Heerlen, Netherlands; Ruihao Wang—Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany; Werner J’Graggen—Department of Neurology, University Hospital Bern, Bern, Switzerland.

**Author contributions** Study conception: A.F., J.C., P.C., C.F.P., P.G., R.H., M.J.H., V.I., J.J., A.P.L.T., I.R., J.S., J.M.S., A.T., G.K.W., E.M., T.B., R.T., W.S., M.H. Study design: A.F., D.R.C., R.H., A.P.L.T., J.S., T.B., R.T., W.S., M.H. Study coordination: A.F., M.H. Data collection: A.F., F.L., N.C., G.C.B., G.C., C.F.P., R.G., P.G., V.I., E.C.A.K., A.K., A.P.L.T., A.T., G.K.W., R.T., W.S., M.H. Data analysis: A.F., M.K.S., F.L., N.C., M.H. Writing of the first draft: A.F. Writing—review and editing: M.K.S., F.L., D.R.C., N.C., G.C.B., J.C., G.C., P.C., C.F.P., R.G., P.G., R.H., M.J.H., V.I., J.J., E.C.A.K., A.K., A.P.L.T., I.R., J.S., J.M.S., A.T., G.K.W., E.M., T.B., R.T., W.S., M.H.

**Funding** Open access funding provided by University of Innsbruck and Medical University of Innsbruck. Academic study without dedicated external financial support. We received administrative support from the EAN Head Office. Dr. Fanciulli, Dr. Leys, and Dr. Campese received travel grants from the Austrian Exchange Program. Dr. Campese is supported by the US MSA Coalition. Dr. Leys is supported by the US
MSA Coalition and the Johannes und Hertha Tuba Stiftung. Financial disclosures for the last 12 months: Alessandra Fanciulli: Dr. Fanciulli reports royalties from Springer Verlag, speaker fees and honoraria from Theravance Biopharma, GE Health Care, Austrian Autonomic Society, Stopp-HSP, Elsevier, and research grants from the FWF-Austrian Science Fund, Medical University of Innsbruck, US MSA Coalition, and Dr Johannes and Hertha Tuba Foundation, outside of the present work. Magdalena Krbot Skorić: Dr Krbot Skoric reports consultation and/or speaker fees from Sanofi Genzyme and Roche, outside of the present work. Fabian Leys: Dr. Leys has nothing to disclose. Diogo Reis Carneiro: Dr. Reis-Carneiro reports speaker fees from Abbvie and Zambon, outside of the present work. Nicole Campese: Dr. Campese has nothing to disclose. Giovanna Calandra-Buonaura: Dr. Calandra-Buonaura reports speaker fees from Zambon and Bial, outside of the present work. Jennifer Camaradou: Ms. Camaradou reports speaker fees from MEDABLE Inc, Reuters Pharma events, Patients as Partners Europe and consultancy fees from Roche Global, GlaxosmithKline GSK, the FutureScience Group and Springer Healthcare (scientific publishing) outside of the scope of current work. Ms. Camaradou is a current assigned lay member of the UK NICE Covid Expert panel, a former Citizen partner at COVID END Evidence synthesis network, and former speaker at Cochrane Convenes. Ms. Camaradou is part of the strategic advisory board for EU project DIGITPREDICT (GA no. 101017915) Edge AI deployed Digital Twins for predicting disease progression and need for early intervention in infectious and cardiovascular disease beyond Covid-19 and part of the community advisory for EU project RBDCOV which is developing an adjuvant recombinant protein vaccine*, based on a receptor binding domain* (RBD) fusion heterodimer against SARS-CoV-2. Giacomo Chiaro: Dr. Chiaro has nothing to disclose. Pietro Cortelli: Dr. Pietro Cortelli has nothing to disclose. Cristian Falup-Pecurariu: Dr. Falup-Pecurariu reports editor fees from Springer and Elsevier; speaker fees from Abbvie and from the International Parkinson and Movement Disorder Society (MDS), outside of the present work. Roberta Granata: Dr. Granata has nothing to disclose. Pietro Guaraldi: Dr. Guaraldi has been advisory board member of Alnylam and Sobi; received speaker fees and honoraria from Alnylam, Akcea Therapeutics, Chiesi, and Theravance Biopharma. Received congress and travel accommodation expense compensations from Abbvie, AB Pharm, Alnylam, Bial, and Zambon, outside of the present work. Raimund Helbok: Dr. Helbok reports honoraria from companies and societies outside of the present work and research grants from the Austrian Science Fund (FWF) related to COVID-19. Max J. Hilz: Dr. Hilz reports consultancy and speaker fees from Sanofi Genzyme and from Amicus Therapeutics, consultancy fees from Pfizer, and editor honoraria from Elsevier BV, outside of the present work. Valeria Iodice: Dr. Iodice reports speaker fees and honoraria from Theravance Biopharma and Janssen, outside of the present work. Jens Jordan: Dr. Jordan served a consultant for Menarini and Novo-Nordisk, received research support from Novo-Nordisk and Boehringer-Ingelheim, and is Co-Founder of Eternxygen GmbH, outside of the present work. Evert C. A. Kaal: Dr. Kaal has nothing to disclose. Anita Kamondi: Dr. Kamondi reports speaker fee from Eisai, outside of the present work. Anne Pavy Le Traon: Dr. Pavy Le Traon reports speaker fees from Alnylan and honoraria from Biohaven, outside of the present work. Isabel Rocha: Dr. Rocha has nothing to disclose. Johann Sellner: Dr. Sellner reports honoraria for lectures, the assembly of teaching material or participation in advisory boards from Alexion, Angelini, BMS, Biogen, Boehringer, Horizon, Janssen, Kedrion, Merck, Novartis, Immunic, Sandoz, and Sanofi, outside of the present work. Jean Michel Senard: Dr. Senard has nothing to disclose. Astrid Terkelsen: Dr. Terkelsen reports consultation and/or speaker fees from Alnylam Pharmaceuticals, Akcea Therapeutics, Pfizer, and Allergan, outside of the present work. Gregor K. Wenning: Dr. Wenning reports consultancy and lecture fees from Inhibicase, Ono, and Theravance and research grants from the FWF-Austrian Science Fund, US MSA Coalition, Parkinson Fonds Austria, Dr. Johannes und Hertha Tuba Foundation, outside of

the present work. Thomas Berger: Dr. Berger has participated in meetings sponsored by and received honoraria (lectures, advisory boards, consultations) from pharmaceutical companies marketing treatments for MS: Allergan, Bayer, Biogen, Bionorica, BMS/Celgene, GSK, GWD/Jazz Pharma, Horizon, Janssen-Cilag, MedDay, Merck, Novartis, Octapharma, Roche, Sandoz, Sanofi-Genzyme, and Teva. His institution has received financial support in the past 12 months by unrestricted research grants (Biogen, Bayer, BMS/Celgene, Merck, Novartis, Sanofi Aventis, Teva) and for participation in clinical trials in multiple sclerosis and related disorders sponsored by Alexion, Bayer, Biogen, BMS/Celgene, Merck, Novartis, Octapharma, Roche, Sanofi-Genzyme, Teva, outside of the present work. Elena Moro: Dr. Moro reports honoraria from Medtronic and research grant from Abbott, Ipsen, and France Parkinson, outside the present work. Roland Thijs: Dr. Thijs received research support from Medtronic, the Human Measurement Models Programme co-funded by Health~ Holland, Top Sector Life Sciences & Health and ZonMw (Brain@Home—agreement 114025101), Michael J Fox Foundation, Epilepsie NL and received speaker or consultancy fees from Theravance Biopharma, Arvelle, Medtronic, Zogenix, Xenon, Angelini, UCB, NewLife Wearables, and Novartis, outside of the present work. Walter Struhal: Dr. Struhal reports royalties from Manz-Rechtsverlag, Springer, Oxford University Press, honorarium from Elsevier, speaker fees from Medconvent, Donau-Universität Krems, Austrian Neurology Society and Manz-Rechtsverlag, outside of the present work. Mario Habek: Dr. Habek participated as a clinical investigator and/or received consultation and/or speaker fees from Biogen, Sanofi Genzyme, Merck, Bayer, Novartis, Pliva/Teva, Roche, Alvogen, Actelion, Alexion Pharmaceuticals, and TG Pharmaceuticals, outside of the present work.

## Declarations

**Conflict of interest** The authors declare no competing interests. Full financial disclosures of the authors are reported above.

**Ethical standards** Survey studies among healthcare professionals do not require an institutional review board approval per Austrian law. All participants gave electronic informed consent before answering the survey and for being listed among the collaborators of the European Network of Neurological Autonomic Laboratories in the resulting publications. The study adhered to the rules of good scientific practice of the Austrian Agency for Research Integrity and to the European General Data Protection Regulation.

**Open Access** This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

## References

1. Artusi CA, Imbalzano G, Sturchio A, Pilotto A, Montanaro E, Padovani A, Lopiano L, Maetzler W, Espay AJ (2020) Implementation of mobile health technologies in clinical trials of
movement disorders: underutilized potential. Neurotherapeutics
17:1736–1746

2. Audisio K, Lia H, Robinson NB, Rahouma M, Soletti G Jr, Cacelli G, Perezgrovas Olaria R, Chadow D, Tam DY, Vervoort D, Farkouh ME, Bhatt DL, Fremes SE, Gaudino M (2022) Impact of the COVID-19 pandemic on non-COVID-19 clinical trials. J Cardiovasc Dev Dis 9:19

3. Blaise D, Berger P, Mokart D, Camerlo J, Fougereau E, Giovannini M, Houvenaeghel G, Turrini O, Chabannon C, Piana G, Brenot-Rossi I, Tallet A, Goncalves A, Charbonnier A, Vey N, Grossi S, Viens P (2021) The management of a comprehensive cancer center during the first six months of the COVID-19 pandemic in the south of France: lessons from the Paoli-Calmettes Institute's Experience. Clin Hematol Int 3:119–129

4. Bodini B, Moro E, Jaarsma J, Cunningham E, Sellner J, Walsh D, Force EAC-T (2022) Lessons learned from people with neurological diseases at the time of COVID-19: The EFNA-EAN survey. Eur J Neurol 29:318–323

5. Bratan T, Aichinger H, Brkic N, Rueter J, Apfelbacher C, Boyer L, Loss J (2021) Impact of the COVID-19 pandemic on ongoing health research: an ad hoc survey among investigators in Germany. BMJ Open 11:e049086

6. Callaway Kim K, Tadrous M, Kane-Gill SL, Barbash IJ, Rothenberger SD, Suda KJ (2021) Changes in purchases for intensive care medicines during the COVID-19 pandemic: a global time series study. Chest 160:2123–2134

7. Cheng T, Chen T, Liu Y, Aldridge RW, Nguyen V, Hayward AC, Michie S (2022) Human mobility variations in response to restriction policies during the COVID-19 pandemic: an analysis from the Virus Watch community cohort in England, UK. Front Public Health 10:999521

8. Cubo E, Arnaiz-Rodriguez A, Arnaiz-Gonzalez A, Diez-Pastor JF, Spindler M, Cardozo A, Garcia-Bustillo A, Mari Z, Bloem BR (2021) Videoconferencing software options for telemedicine: a review for movement disorder neurologists. Front Neurol 12:745917

9. Cuffaro L, Carvalho V, Di Liberto G, Klingelehoefer L, Sauerbier A, Garcia-Azorin D, Tabuas-Pereira M, Vashchenko N, Moro E, Bassetti CLA (2021) Neurology training and research in the COVID-19 pandemic: a survey of the Resident and Research Fellow Section of the European Academy of Neurology. Eur J Neurol 28:3437–3442

10. Davies EH, Matthews C, Merlet A, Zimmermann M (2022) Time to see the difference: video capture for patient-centered clinical trials. Patient 15:389

11. Dedeilia A, Papapanou M, Papadopoulos AN, Karela NR, Androutsou A, Mitsopoulou D, Nikolakea M, Konstantinidis C, Papageorgakopoulou M, Sideris M, Johnson EO, Fitzpatrick S, Cometto G, Campbell J, Sotiropoulos MG (2023) Health worker education during the COVID-19 pandemic: global disruption, responses and lessons for the future-a systematic review and meta-analysis. Hum Resour Health 21:13

12. Fanciulli A, Leys F, Krbot Skoric M, Carneiro DR, Calandra-Buonaura G, Camaradou J, Chiaro G, Cortelli P, Falup-Pecurariu C, Granata R, Guaraldi P, Helbok R, Hilz MJ, Iodice V, Jordan J, Kaal ECA, Kamondi A, Pavy Le Traon A, Rocha I, Sellner J, Senard JM, Terkelsen A, Wenning GK, Moro E, Berger T, Thijs RD, Struhal W, Habek M, Collaborators of European Network of Neurological ANSI (2023) Impact of the COVID-19 pandemic on clinical autonomic practice in Europe A survey of the European Academy of Neurology (EAN) and the European Federation of Autonomic Societies (EFAS). Eur J Neurol 30:1712

13. Frontera JA, Tamborska AA, Doheim MF, Garcia-Azorin D, Gezegen H, Guekht A, Yusof Khan AHK, Santacatterina M, Sejvar J, Thakur KT, Westenberg E, Winkler AS, Beghi E, contributors from the Global C-NRC (2022) Neurological events reported

after COVID-19 vaccines: an analysis of VAERS. Ann Neurol
91:756–771

14. Grobe-Einsler M, Taheri Amin A, Faber J, Schaprian T, Jacobi H, Schmitz-Hubsch T, Diallo A, Tezenas du Montcel S, Klockgether T (2021) Development of SARA (home), a new video-based tool for the assessment of ataxia at home. Mov Disord 36:1242–1246

15. Guadix SW, Winston GM, Chae JK, Haghdel A, Chen J, Younus I, Radwanski R, Greenfield JP, Pannullo SC (2020) Medical student concerns relating to neurosurgery education during COVID-19. World Neurosurg 139:e836–e847

16. Habek M, Leys F, Krbot Skoric M, Reis Carneiro D, Calandra-Buonaura G, Camaradou J, Chiaro G, Cortelli P, Falup-Pecurariu C, Granata R, Guaraldi P, Helbok R, Hilz MJ, Iodice V, Jordan J, Kaal ECA, Kamondi A, Pavy Le Traon A, Rocha I, Sellner J, Senard JM, Terkelsen A, Wenning GK, Berger T, Thijs RD, Struhal W, Fanciulli A, Collaborators of the European Network of Clinical ANSI (2022) Clinical autonomic nervous system laboratories in Europe: A joint survey of the European Academy of Neurology and the European Federation of Autonomic Societies: a joint survey of the European Academy of Neurology and the European Federation of Autonomic Societies. Eur J Neurol 29:3633–3646

17. Hale T, Angrist N, Goldszmidt R, Kira B, Petherick A, Phillips T, Webster S, Cameron-Blake E, Hallas L, Majumdar S, Tatlow H (2021) A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). Nat Hum Behav 5:529–538

18. N Fountoulakis K, N Karakatsoulis G, Abraham S, Adorjan K, Ahmed HU, Alarcón RD, Arai K, Auwal SS, Bobes J, Bobes-Bascaran T, Bourgin-Duchesnay J, Bredicean CA, Bukelskis L, Burkadze A, Cabrera Abud II, Castilla-Puentes R, Cetkovich M, Colon-Rivera H, Corral R, Cortez-Vergara C, Crepin P, de Berardis D, Zamora Delgado S, de Lucena D, de Sousa A, di Stefano R, Dodd S, Elek LP, Elissa A, Erdelyi-Hamza B, Erzin G, Etchevers MJ, Falkai P, Farcas A, Fedotov I, Filatova V, Fountoulakis NK, Frankova I, Franza F, Frias P, Galako T, Garay CJ, Garcia-Álvarez L, García-Portilla P, Gonda X, Gondek TM, Morera González D, Gould H, Grandinetti P, Grau A, Groudeva V, Hagin M, Harada T, Hasan TM, Azreen Hashim N, Hilbig J, Hossain S, lakimova R, Ibrahim M, Iftene F, Ignatenko Y, Irarrazaval M, Ismail Z, Ismayilova J, Jacobs A, Jakovljević M, Jakšić N, Javed A, Yilmaz Kafali H, Karia S, Kazakova O, Khalifa D, Khaustova O, Koh S, Kopishinskaia S, Kosenko K, Koupidis SA, Kovacs I, Kulig B, Lalljee A, Liewig J, Majid A, Malashonkova E, Malik K, Iqbal Malik N, Mammadzada G, Mandalia B, Marazziti D, Marčinko D, Martinez S, Matiekus E, Mejia G, Memon RS, Meza Martínez XE. Mickevičiūtė D, Miley R, Mohammed M, Molina-López A, Morozov P, Muhammad NS, Mustač F, Naor MS, Nassieb A, Navickas A, Okasha T, Pandova M, Panfil AL, Panteleeva L, Papava I, Patsali ME, Pavlichenko A, Pejuskovic B, Pinto da Costa M, Popkov M, Popovic D, Raduan NJN, Vargas Ramírez F, Rancans E, Razali S, Rebok F, Rewekant A, Reyes Flores EN, Rivera-Encinas MT, Saiz PA, Sánchez de Carmona M, Saucedo Martínez D, Saw JA, Saygili G, Schneidereit P, Shah B, Shirasaka T, Silagadze K, Sitanggang S, Skugarevsky O, Spikina A, Mahalingappa SS, Stoyanova M, Szczegielniak A, Tamasan SC, Tavormina G, Tavormina MGM, Theodorakis PN, Tohen M, Tsapakis EM, Tukhvatullina D, Ullah I, Vaidya R, Vega-Dienstmaier JM, Vrublevska J, Vukovic O, Vysotska O, Widiasih N, Yashikhina A, Prezerakos PE, Berk M, Levaj S, Smirnova D. (2023) Results of the COVID-19 mental health international for the health professionals (COMET-HP) study: depression, suicidal tendencies and conspiracism. Soc Psychiatry Psychiatr Epidemiol. 9:1387-1410.

19. Lau B, Tadrous M, Chu C, Hardcastle L, Beall RF (2022) COVID-19 and the prevalence of drug shortages in Canada: a
cross-sectional time-series analysis from April 2017 to April 2022. CMAJ 194:E801–E806

20. Liebensteiner MC, Khosravi I, Hirschmann MT, Heuberer PR, Board of the AGASoA, Joint S, Saffarini M, Thaler M (2020) It is not “business as usual” for orthopaedic surgeons in May 2020—the Austrian-German-Swiss experience. J Exp Orthop 7:61

21. Macerollo A, Rona-Voros K, Holler N, Chiperi R, Gyorfi O, Papp V, Sauerbier A, Balicza P, Sellner J (2015) Preferences of residents and junior neurologists to attend conferences—an EAYNT survey. J Neurol Sci 357:297–299

22. Majid U, Hussain SAS, Zahid A, Haider MH, Arora R (2023) Mental health outcomes in health care providers during the COVID-19 pandemic: an umbrella review. Health Promot Int 38:2

23. Myers TL, Augustine EF, Baloga E, Daeschler M, Cannon P, Rowbotham H, Chanoff E, Me Research T, Jensen-Roberts S, Soto J, Holloway RG, Marras C, Tanner CM, Dorsey ER, Schneider RB (2022) Recruitment for remote decentralized studies in Parkinson's disease. J Parkinson's Dis 12:371–380

24. Naude B, Rigaud AS, Pino M (2021) Video calls for older adults: a narrative review of experiments involving older adults in elderly care institutions. Front Public Health 9:751150

25. NICE (2021) COVID-19 rapid guideline: managing the long-term effects of COVID-19. In: Excellence NIfHaC (ed). NICE, United Kingdom

26. Perego G, Cugnata F, Brombin C, Milano F, Mazzetti M, Taranto P, Preti E, Di Pierro R, De Panfilis C, Madeddu F, Di Mattei VE (2023) Analysis of healthcare workers' mental health during the COVID-19 pandemic: evidence from a three-wave longitudinal study. J Health Psychol:13591053231168040

27. Raccagni C, Goebel G, Gassner H, Granata R, Ndayisaba JP, Seebacher B, Schoenherr G, Mitterhuber J, Hendriks P, Kaindl-storfer C, Eschlboeck S, Fanciulli A, Krismer F, Seppi K, Poewe W, Bloem BR, Klucken J, Wenning GK (2019) Physiotherapy improves motor function in patients with the Parkinson variant of multiple system atrophy: A prospective trial. Parkinson Relat Disord 67:60–65

28. Raccagni C, Sidoroff V, Goebel G, Granata R, Leys F, Klucken J, Eskofier B, Richer R, Seppi K, Wenning GK, Fanciulli A (2020) The footprint of orthostatic hypotension in Parkinsonian syndromes. Parkinson Relat Disord 77:107–109

29. Ranney ML, Griffeth V, Jha AK (2020) Critical supply shortages—the need for ventilators and personal protective equipment during the covid-19 pandemic. N Engl J Med 382:e41

30. Reis-Carneiro DRI, Habek M, Helbok R, Sellner J, Struhal W, Wenning GK, Fanciulli A (2023) Clinical presentation and management strategies of cardiovascular autonomic dysfunction following a COVID-19 infection—a systematic review. Eur J Neurol 30:1528

31. Russo V, Boggian G, Bolognesi MG, Carretta DM, Cencetti S, De Laura D, Hrovatin E, Pastori P, Tomaselli C, Parente E, Rafanelli M, Ungar A, On Behalf Of Covid-Gimsi Study G (2021) The impact of COVID-19 outbreak on syncope units activities in Italy: a report from the Italian Multidisciplinary Working Group on Syncope (GIMSI). Int J Environ Res Public Health 18:9194

32. Sandrone S, Albert DV, Dunham SR, Kraker J, Noviawaty I, Palm M, Kushlaf H (2021) Training in neurology: how lessons learned on teaching, well-being and telemedicine during the COVID-19 pandemic can shape the future of neurology education. Neurology 96:e3007-3010

33. Stamelou M, Struhal W, Ten Cate O, Matczak M, Caliskan SA, Soffietti R, Marson A, Zis P, di Lorenzo F, Sander A, Deuschl G, de Visser M, Bassetti CLA (2021) Evaluation of the 2020 European Academy of Neurology virtual congress: transition from a face-to-face to a virtual meeting. Eur J Neurol 28:2523–2532

34. Struhal W, Sellner J, Eynt (2009) European teaching course on autonomic nervous system disorders : reaching out to young physicians. Clin Auton Res 19:130

35. Suda KJ, Kim KC, Hernandez I, Gellad WF, Rothenberger S, Campbell A, Malliart L (2003) Tadrous M (2022) The global impact of COVID-19 on drug purchases: a cross-sectional time series analysis. J Am Pharm Assoc 62(766–774):e766

36. WHO (2023) WHO coronavirus (COVID-19) Dashboard. Available at: https://covid19.who.int/

37. Wong KLM, Gimma A, Coletti P, CoMix Europe Working G, Faes C, Beutels P, Hens N, Jaeger VK, Karch A, Johnson H, Edmunds W, Jarvis CI (2023) Social contact patterns during the COVID-19 pandemic in 21 European countries—evidence from a two-year study. BMC Infect Dis 23:268

## Authors and Affiliations

Alessandra Fanciulli¹ ID · Magdalena Krbot Skoric²,³ · Fabian Leys¹ · Diogo Reis Carneiro⁴,⁵ · Nicole Campese¹ ·

Giovanna Calandra-Buonaura⁶,⁷ · Jennifer Camaradou⁸,⁹ · Giacomo Chiaro¹⁰,¹¹ · Pietro Cortelli⁶,⁷ ·

Cristian Falup-Pecurariu¹² · Roberta Granata¹ · Pietro Guaraldi⁶ · Raimund Helbok¹,¹³ · Max J. Hilz¹⁴,¹⁵ ·

Valeria Iodice¹⁰,¹¹ · Jens Jordan¹⁶,¹⁷ · Evert C. A. Kaal¹⁸ · Anita Kamondi¹⁹,²⁰ · Anne Pavy Le Traon²¹ · Isabel Rocha²² ·

Johann Sellner²³,²⁴ · Jean Michel Senard²⁵ · Astrid Terkelsen²⁶ · Gregor K. Wenning¹ · Elena Moro²⁷ ·

Thomas Berger²⁸,²⁹ · Roland D. Thijs³⁰,³¹ · Walter Struhal³² · Mario Habek²,³³ · the Collaborators of European Network of Neurological Autonomic Laboratories

<figure><img src="image_14.png" /></figure>

Alessandra Fanciulli
alessandra.fanciulli@i-med.ac.at

¹ Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria

² Department of Neurology, University Hospital Centre, Zagreb, Croatia

³ Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia

⁴ Department of Neurology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal

⁵ Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

⁶ IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy

⁷ Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
8. Patient Partner of the EAN Scientific Panel for Autonomic Nervous System Disorders, London, UK

9. Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK

10. Autonomic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK

11. UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK

12. Department of Neurology, Faculty of Medicine, Transilvania University, Brasov, Romania

13. Department of Neurology, Johannes Kepler University, Linz, Austria

14. Icahn School of Medicine at Mount Sinai, New York, NY, USA

15. Department of Neurology, University Erlangen-Nuremberg, Erlangen, Germany

16. German Aerospace Center, Cologne, Germany

17. Medical Faculty, University of Cologne, Cologne, Germany

18. Department of Neurology, Maasstad Ziekenhuis, Rotterdam, The Netherlands

19. Department of Neurology, National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary

20. Department of Neurology, Semmelweis University, Budapest, Hungary

21. Department of Neurology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France

22. Cardiovascular Autonomic Function Lab, Faculty of Medicine and CCUL, University of Lisbon, Lisbon, Portugal

23. Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria

24. Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

25. Institut des Maladies Métaboliques et Cardiovasculaires, INSERM U 1297, Toulouse, France

26. Department of Neurology, Aarhus University Hospital and Danish Pain Research Center, Aarhus University, Aarhus, Denmark

27. Division of Neurology, Grenoble Institute of Neuroscience, Grenoble Alpes University, CHU of Grenoble, Grenoble, France

28. Department of Neurology, Medical University of Vienna, Vienna, Austria

29. Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria

30. Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands

31. Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands

32. Department of Neurology, University Hospital Tulln, Karl Landsteiner University of Health Sciences, Tulln, Austria

33. Department of Neurology, University of Zagreb, School of Medicine, Zagreb, Croatia

<figure><img src="image_15.png" /></figure>