Telemedicine, or the ability to conduct some physician consultations online, is having its moment. Envisioned by pioneers as the next revolution in promoting medical access, its popularity soared during the COVID-19 pandemic, when movement controls were initiated in many parts of the world. 

Today, regulators, physicians, and patients agree: telemedicine is here to stay. The debate now moves on to how telemedicine can be stretched to its full potential, while recognizing its clear limitations and the risk for negligence. 

One area in which telemedicine has been seen as particularly promising is in monitoring a patient’s physical motor abilities, especially when the patient has a chronic (as opposed to acute) neuromuscular disorder such as myasthenia gravis. In the past, healthcare professionals would need to make home visits to monitor disability progression; with the advent of telemedicine, all this can be done online, saving time and money. 

“Telemedicine may be particularly well-suited for myasthenia gravis due to the disorder’s need for specialized care, its hallmark fluctuating muscle weakness and the potential for increased risk of virus exposure among patients with [myasthenia gravis] during the COVID-19 pandemic during in-person clinical visits,” Guidon and colleagues wrote in Muscle & Nerve. 

The researchers, therefore, conducted a study on the fundamentals that must be included in an assessment of a patient with myasthenia gravis via telemedicine. 

Measuring Disability Progression 

Guidon and colleagues conducted their study during April and May of 2020, early months of the COVID-19 pandemic. This was a phase of the pandemic during which large sections of the world had some movement control measures in place. Hence, telemedicine was seen as a necessity in order for clinicians and patients to stay up to date with their planned follow-ups. 

The study was a series of meetings between experts on myasthenia gravis, researchers, neuromuscular trainees, and clinicians with expertise in telemedicine. They met virtually once weekly over 4 weeks. Their discussion culminated in consensus on a series of steps needed to provide quality care for patients with myasthenia gravis via telemedicine. 

During a telemedicine session with the patient, it is important that physicians take a detailed history of the patient’s disease. The Myasthenia Gravis Activities of Daily Living scale can be immensely helpful for this purpose. In addition, physicians should ask about current medications that their patients are taking. 

Read more about myasthenia gravis etiology 

The “general examination” phase of a telemedicine appointment can prove to be extremely difficult and downright impossible in some cases (such as examining a patient complaining of unspecified abdominal pain). However, in the case of neuromuscular diseases such as myasthenia gravis, this can be done online if it is done professionally and methodically. 

The first thing that physicians should take note of is any change in the patient’s general appearance or mental status since the last appointment. Among features that should be noticed are any Cushingoid or skin changes, particularly if the patient is on corticosteroids. 

“The following 8 core elements are recommended for all telemedicine assessments of [myasthenia gravis]: ptosis, diplopia, facial strength, bulbar strength, counting to 50, arm strength, single breath count, and sit-to-stand,” Guidon and colleagues wrote. “The assessment takes approximately 10 minutes.” 

Once these elements have been assessed, it is essential that physicians document their virtual visits methodically. The authors of the study suggested documenting the platform used for the telemedicine call, physician and patient location, other persons in attendance, duration of the call, and evidence of consent for both the platform used and the billing obtained. 

It is important for medicolegal reasons that any changes to the patient’s medications are documented clearly. If the patient requires additional testing or monitoring at a physical location, this should be duly documented by the attending physician. 

“Expanding access to technology and improving patient readiness for telemedicine and the accessibility of the interface should be considered into the development of future programs,” Guidon et al concluded. “For these reasons, additional study of telemedicine feasibility, acceptability, and outcomes in [myasthenia gravis] both during and after the COVID-19 pandemic is planned.” 

Comparing MG and DMD in the Context of Telemedicine

In the Central European Journal of Medicine, Sobierajska-Rek and colleagues conducted a study to determine the feasibility of a telerehabilitation program for patients with Duchenne muscular dystrophy (DMD). DMD is similar to myasthenia gravis in that it is also a chronic neuromuscular disease that manifests as muscular weakness. Its similarities with myasthenia gravis mean that it shares the same promises and pitfalls with regards to telemedicine. 

Read more about DMD etiology 

Sobierajska-Rek and colleagues conducted a rehabilitation program presented via online workshops for patients and their caregivers. Their program included 6 online motor skill assessments; upon the completion of these tests, caregivers were asked to share a photograph of the patient’s posture via a designated app. 

“With the physiotherapist’s guidance (online communication or video), patients with caregivers’ help can continue home-based rehabilitation of respiratory physiotherapy, stretching, and strengthening exercises,” the authors of the study concluded. 

Both of these studies indicate that telemedicine can be hugely effective for the remote monitoring of disease progression among patients with chronic neuromuscular disorders. Future studies should be focused on investigating whether this technological tool can similarly aid follow-up in patients with other neuromuscular disorders, such as amyotrophic lateral sclerosis and polymyositis.

References

Guidon AC, Muppidi S, Nowak RJ, et al. Telemedicine visits in myasthenia gravis: expert guidance and the Myasthenia Gravis Core Exam (MG-CE)Muscle Nerve. 2021;64(3):270-276. doi:10.1002/mus.27260

Sobierajska-Rek A, Mański Ł, Jabłońska-Brudło J, Śledzińska K, Ucińska A, Wierzba J. Establishing a telerehabilitation program for patients with Duchenne muscular dystrophy in the COVID-19 pandemicWien Klin Wochenschr. 2021;133(7-8):344-350. doi:10.1007/s00508-020-01786-8