Telemedicine Chapter 13: Telemedicine and Multiple Sclerosis

This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020

Systematic Reviews

Di Tella, Sonia et al (2019) [Systematic Review and Meta-Analysis]
Integrated telerehabilitation approach in multiple sclerosis: A systematic review and meta-analysis1

Introduction: Multiple sclerosis (MS)is a chronic immune-mediated disease of the central nervous system and a major cause of disability in young adults. Recently, there has been a growing interest in the development of innovative ways to deliver rehabilitation care outside of a hospital setting. The aim was to conduct a systematic review and a meta-analysis of the efficacy of an integrated telerehabilitation approach (ITA) on motor, cognitive and participation outcomes delivered to people with MS (pwMS).

Methods: We systematically searched for original manuscripts regarding ITA in pwMS. Efficacy on motor, cognitive and participation outcomes was measured as the standardized mean difference [Hedges’ g] of pre and post training.

Results: Nine studies encompassing 716 pwMS diagnosis were included. The overall effect of ITA was: large for motor outcomes (g=1.05; p=0.013); small for cognitive performance outcomes (g=0.16; p=0.237); and small for participation outcomes (g=0.15; p=0.259). Domain-specific results showed that the effect on motor disability was large (g=1.18), while on gait and balance was medium (g=0.32 and g=0.48, respectively). Moreover, all effects on single cognitive domains were small. Finally, among the single participation outcomes considered (depression, fatigue, daily functioning, quality of life and self-efficacy), only depression showed a nearly medium effect (g=0.30).

Conclusions: PwMS can benefit from ITA in the treatment of motor symptoms according to the current model of continuity of care. However, the low efficacy of ITA on cognition and participation domains suggests the necessity to develop intervention models that include a broader spectrum of needs and objectives.

Randomised Controlled Trials

Charvet, Leigh E et al (2017) [Randomised Controlled Trial]Cognitive Function in Multiple Sclerosis Improves With Telerehabilitation: Results From a Randomized Controlled Trial2

Cognitive impairment affects more than half of all individuals living with multiple sclerosis (MS). We hypothesized that training at home with an adaptive online cognitive training program would have greater cognitive benefit than ordinary computer games in cognitively-impaired adults with MS. This was a double-blind, randomized, active-placebo-controlled trial. Participants with MS were recruited through Stony Brook Medicine and randomly assigned to either the adaptive cognitive remediation (ACR) program or active control of ordinary computer games for 60 hours over 12 weeks. Training was remotely-supervised and delivered through a study provided laptop computer. A computer generated, blocked stratification table prepared by statistician provided the randomization schedule and condition was assigned by a study technician.

The primary outcome, administered by study psychometrician, was measured by change in a neuropsychological composite measure from baseline to study end. An intent-to-treat analysis was employed and missing primary outcome values were imputed via Markov Chain Monte Carlo method. Participants in the ACR (n = 74) vs. active control (n = 61)training program had significantly greater improvement in the primary outcome of cognitive functioning (mean change in composite z score±SD: 0·25±0·45 vs. 0·09±0·37, p = 0·03, estimated difference = 0·16 with 95% CI: 0·02-0·30), despite greater training time in the active control condition (mean±SD:56·9 ± 34·6 vs. 37·7 ±23 ·8 hours played, p = 0·006).

This study provides Class I evidence that adaptive, computer-based cognitive remediation accessed from home can improve cognitive functioning in MS. This telerehabilitation approach allowed for rapid recruitment and high compliance, and can be readily applied to other neurological conditions associated with cognitive dysfunction. Trial registration: NCT02141386.

Guijarro-Castro, C. et al (2017) [Randomised Controlled Trial] Face-to-Face or Telematic Cognitive Stimulation in Patients With Multiple Sclerosis and Cognitive Impairment: Why Not Both?3

Introduction: Cognitive impairment (CI) affects 40-65% of patients with multiple sclerosis (MS). Few studies address telematic cognitive stimulation (TCS)in MS. The objective of this study is to evaluate the efficacy and impact of telestimulation or distance cognitive stimulation (TCS), with and without the support of face-to-face cognitive stimulation (FCS)in cognitive impairment in MS. Methods: Multicentre, prospective, randomised, controlled study. We will include 98 MS patients with EDSS ≤ 6, symbol digit modality test (SDMT) ≤ Pc 25, and Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNQ) > 26 points. Patients will be randomised into 3 groups, a TCS group, a mixed TCS/FCS group, and a control group. CS is performed 3 days a week for 3 months. Processing speed, memory, attention, and executive functions will be rehabilitated. FCS will include ecological exercises and strategies. EDSS and a cognitive evaluation (SDMT, CTMT, PASAT, and TAVEC), MSNQ, psychological impact scales (MSIS), and depression (BDI) will be carried out, baseline, post-rehabilitation, and also 6 and 12 months later, to evaluate the effect of CS in the longer term. Conclusion: This study could help to establish the usefulness of TCS or, in its absence, TCS with face-to-face help for CI in MS. The interest lies in the clear benefits of remote rehabilitation in the daily life of patients.


Creagh, Andrew et al (2020) [Review] Smartphone-based remote assessment of upper extremity function for multiple sclerosis using the FLOODLIGHT draw a shape test4

Objective: Smartphone devices may enable out-of-clinic assessments in chronic neurological diseases. We describe the FLOODLIGHT Draw a Shape (DaS) Test, a smartphone-based and remotely administered test of Upper Extremity (UE)function developed for people with multiple sclerosis (PwMS). This work introduces DaS-related features that characterise UE function and impairment, and aims to demonstrate how multivariate modelling of these metrics can reliably predict the 9-Hole Peg Test (9HPT), a clinician-administered UE assessment in PwMS.

Approach: The FLOODLIGHT DaS test instructed PwMS and healthy controls (HC)to trace predefined shapes on a smartphone screen. A total of 93 subjects (HC, n=22; PwMS, n=71) contributed both dominant and non-dominant handed DaS tests. PwMS subjects were characterised as those with normal (nPwMS, n=50) and abnormal UE function (aPwMS, n=21) with respect to their average 9HPT time (≤ or >22.7 [s], respectively). L1-regularization techniques, combined with linear least squares (OLS, IRLS), or non-linear Support Vector (SVR) or Random Forest (RFR) regression were investigated as functions to map relevant DaS features to 9HPT times.

Main results: It was observed that average non-dominant handed 9HPT times were more accurately predicted by DaS features (r^2=0.41, P<0.05; MAE: 2.08 ± 0.34 [s])than average dominant handed 9HPTs (r^2=0.39, P<0.05; MAE: 2.32 ± 0.43 [s]), using simple linear IRLS (P<0.01). Moreover, it was found that the Mean absolute error (MAE)in predicted 9HPTs was comparable to the variability of actual 9HPT times within HC, nPwMS and aPwMS groups respectively. The 9HPT however exhibited large heteroscedasticity resulting in less stable predictions of longer 9HPT times. Significance: This study demonstrates the potential of the smartphone-based DaS Test to reliably predict 9HPT times and remotely monitor UE function in PwMS.

Matthews, Paul M et al (2020) [Review] E-health and Multiple Sclerosis5

Purpose: To outline recent applications of e-health data and digital tools for improving the care and management of healthcare for people with multiple sclerosis.

Recent Findings: The digitization of most clinical data, along with developments in communication technologies, miniaturization of sensors and computational advances are enabling aggregation and clinically meaningful analyses of real-world data from patient registries, digital patient-reported outcomes and electronic health records (EHR). These data are allowing more confident descriptions of prognoses for multiple sclerosis patients and the long-term relative benefits and safety of disease-modifying treatments (DMT). Registries allow detailed, multiple sclerosis-specific data to be shared between clinicians more easily, provide data needed to improve the impact of DMT and, with EHR, characterize clinically relevant interactions between multiple sclerosis and other diseases. Wearable sensors provide continuous, long-term measures of performance dynamics in relevant ecological settings. In conjunction with telemedicine and online apps, they promise a major expansion of the scope for patients to manage aspects of their own care. Advances in disease understanding, decision support and self-management using these Big Data are being accelerated by machine learning and artificial intelligence.

Summary: Both health professionals and patients can employ e-health approaches and tools for development of a more patient-centred learning health system.

Remy, Caroline et al (2020) [Cross-Sectional Study] Telecommunication and rehabilitation for patients with multiple sclerosis. Access and willingness to use: a cross-sectional study6

Background: Telerehabilitation is a promising approach for patients with multiple sclerosis (MS), but uncertainties regarding patients’ access and preferences remain. Aim: To investigate the access to telecommunication technologies and rehabilitation services of patients with MS, and their willingness to use these technologies for rehabilitation.

Design: Crosssectional survey. Setting: Outpatient neurological facility. Population: Patients with MS.

Methods: Patients with MS attending consultations in the Neurology department were asked to fill in a paper questionnaire. This anonymous questionnaire was designed to gain information about needs and access to rehabilitation and telecommunication technologies, as well as interests and perspectives of telerehabilitation among these patients. Descriptive statistics, chi- squared tests and logistic regressions were used to describe the sample and survey answers.

Results: Two hundred patients completed the questionnaire. Mean age was 44.41(±12.52) years. Seventy-one percent were women, and 49% were unemployed. Ninety-one percent of the patients regularly used Internet and 73% used apps. Most patients were interested in using telecommunication technologies to receive a program of physical exercises (62%), for information and personalized advice about physical activity and MS (69%), and to communicate with caregivers (75%). Patients with EDSS>4 were less interested than patients with EDSS≤4 in communicating with the caregivers via apps (33%vs52%,Δ19%[CI-36%;- 2%],p=0.04) but expressed greater interest in receiving information and personal advice about physical activity and MS via the Internet (70%vs51%,Δ19%[CI+2%;+36%],p=0.03). One third of the patients was not interested in receiving telerehabilitation interventions (32%), notably patients with EDSS>4 and non-workers.

Conclusions: Patients with MS are mainly interested in using telecommunication technologies for rehabilitation services, and most of these patients have access to the required technology. Being mildly disabled and having a professional activity are associated with a greater interest in telerehabilitation. In contrary, patients with moderate-to-severe disability and non-workers have reportedly less access and ease in using the required technologies. Clinical rehabilitation impact: Telerehabilitation is feasible and wished by patients with MS, specifically in patients with low EDSS scores and workers. Given the strong need for rehabilitation in more disabled patients, the barriers to its access, the lower access and ease of use of telecommunication technologies, a special effort is needed to facilitate their use in these patients.

Amatya, Bhasker et a l(2019) [Overview] Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews7

Background: Multiple sclerosis (MS)is a major cause of chronic, neurological disability, with a significant long-term disability burden, often requiring comprehensive rehabilitation. Objectives: To systematically evaluate evidence from published Cochrane Reviews of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS (pwMS), to improve patient outcomes, and to highlight current gaps in knowledge.

Methods: We searched the Cochrane Database of Systematic Reviews up to December 2017, to identify Cochrane Reviews that assessed the effectiveness of organised rehabilitation interventions for pwMS. Two reviewers independently assessed the quality of included reviews, using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR)tool, and the quality of the evidence for reported outcomes, using the GRADE framework.

Main results: Overall, we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants. The included reviews evaluated a wide range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy (HBOT), whole-body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity. We assessed all reviews to be of high to moderate methodological quality, based on R-AMSTAR criteria. Moderate quality evidence suggested that physical therapeutic modalities improved functional outcomes, reduced impairment, and improved participation. Moderate-quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation, and interventions that provided information improved patient knowledge. Low-qualitty evidence suggested that neuropsychological interventions, symptom-management programmes, whole body vibration, and telerehabilitation improved some patient outcomes. Evidence for other rehabilitation modalities was inconclusive, due to lack of robust studies.

Authors’ Conclusions: The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit, although the certainty of evidence varies across the different types of interventions evaluated by the reviews. Structured, multidisciplinary rehabilitation programmes and physical therapy can improve functional outcomes [mobility, muscle strength, aerobic capacity], and quality of life. Overall, the evidence for many rehabilitation interventions should be interpreted cautiously, as the majority of included reviews did not include data from current studies. More studies, with appropriate design, which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge. The authors acknowledge that four included reviews were conducted by the present authors’ team (Amatya 2013; Khan 2007b; Khan 2009; Khan 2015), and one author (FK) was involved in another review (Kopke 2014).

Block, ValerieJ et al (2019) [Observational Study] Association of Continuous Assessment of Step Count by Remote Monitoring With Disability Progression Among Adults With Multiple Sclerosis8

Importance: Disability measures in multiple sclerosis (MS)fail to capture potentially important variability in walking behavior. More sensitive and ecologically valid outcome measures are needed to advance MS research. Objectives: To assess continuous step count activity remotely among individuals with MS for 1 year and determine how average daily step count is associated with other measures of MS disability. Design, Setting, and Participants: In a prospective longitudinal observational cohort study, 95 adults with relapsing or progressive MS who were able to walk more than 2 minutes with or without an assistive device were recruited between June 15, 2015, and August 8, 2016, and remotely monitored in their natural environment for 1 year. Patients were excluded if they had a clinical relapse within 30 days or comorbidity contributing to ambulatory impairment. Longitudinal analysis was performed from October 2017 to March 2018. Revised analysis was performed in December 2018.

Intervention: Activity monitoring of step count using a wrist-worn accelerometer.

Main Outcomes and Measures: Average daily step count compared with inclinic assessments and patient-reported outcomes. Results: of the 95 participants recruited (59 women and 36 men; mean [SD] age, 49.6 [13.6] years [range, 22.0-74.0 years]), 35 (37%) had progressive MS, and the median baseline Expanded Disability Status Scale score was 4.0 (range, 0- 6.5). At 1 year, 79 participants completed follow-up (83% retention). There was a modest reduction in accelerometer use during the 1 year of the study. A decreasing average daily step count during the study was associated with worsening of clinic-based outcomes (Timed 25-Foot Walk, β= -13.09; P < .001; Timed-Up-and-Go, β = -9.25; P < .001) and patient-reported outcomes (12-item Multiple Sclerosis Walking Scale, β = -17.96; P < .001). A decreasing average daily step count occurred even when the Expanded Disability Status Scale score remained stable, and 12 of 25 participants (48%) with a significant decrease in average daily step count during the study did not have a reduction on other standard clinic-based metrics. Participants with a baseline average daily step count below 4766 (cohort median) had higher odds of clinically meaningful disability (Expanded Disability Status Scale score) worsening at 1 year, adjusting for age, sex, and disease duration (odds ratio, 4.01; 95% CI, 1.17-13.78; P = .03).

Conclusions and Relevance: Continuous remote activity monitoring of individuals with MS for 1 year appears to be feasible. In this study, a decreasing average daily step count during a 1-year period was associated with worsening of standard ambulatory measures but could also occur even when traditional disability measures remained stable. These results appear to support the prospect of using the average daily step count as a sensitive longitudinal outcome measure in MS and as a clinically relevant metric for targeted intervention. Conflict of Interest Disclosures: Dr Bove reported receiving personal fees from Novartis, RocheGenentech, and Genzyme-Sanofi; and receiving grants from Akili Interactive outside the submitted work. Dr Graves reported receiving personal fees from Novartis outside the submitted work. Dr Romeo reported receiving grants from the National Multiple Sclerosis Society outside the submitted work. Dr Green reported serving on scientific advisory boards or trial execution committees for MedImmune (VielaBio), Novartis, Inception 5 Sciences, Pipeline, and Bionure; holding a patent for remyelination molecules and pathways; receiving research support from Novartis, Inception Sciences, the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, the National Institutes of Health, National Multiple Sclerosis Society, Sherak Foundation, and Hilton Foundation; and serving as an expert witness in Mylan Pharmaceuticals v Teva Pharmaceuticals. Dr Olgin reported receiving grants from Zoll; and personal fees from Novartis and from Vivalink outside the submitted work. Dr Marcus reported receiving grants from Jawbone Health during the conduct of the study. Dr Cree reported receiving personal consulting fees from AbbVieAkili, Biogen, EMD Serono, GeNeuro, and Novartis outside the submitted work. Dr Gelfand reported receiving grants to University of California, San Francisco from Genentech; receiving service contract support to University of California, San Francisco from MedDay; receiving personal fees from Alexion and from Biogen outside the submitted work; and receiving personal compensation for medical legal consulting and serving as an expert witness outside the submitted work. No other disclosures were reported.

Block, ValerieJ et al (2019) [Review] Validation of a consumer-grade activity monitor for continuous daily activity monitoring in individuals with multiple sclerosis9

Background: Technological advancements of remote-monitoring used in clinical-care and research require validation of model updates. Objectives: To compare the output of a newer consumer-grade accelerometer to a previous model in people with multiple sclerosis (MS) and to the ActiGraph, a waistworn device widely used in MS research.

Methods: Thirty-one individuals with MS participated in a 7-day validation by the Fitbit Flex (Flex), Fitbit Flex2 (Flex2) and ActiGraph GT3X. Primary outcome was step count. Valid epochs of 5-min block increments, where there was overlap of ≥1 step/min for both devices were compared and summed to give a daily total for analysis.

Results: Bland-Altman plots showed no systematic difference between the Flex and Flex2; mean step-count difference of 25 more steps-per-day more recorded by Flex2 (95% confidence intervals (CI) = 2, 48; p = 0.04), interclass correlation coefficient (ICC) = 1.00. Compared to the ActiGraph, Flex2 (and Flex)tended to record more steps (808 steps-per-day more than the ActiGraph (95% CI= -2380, 765; p < 0.01), although the ICC was high (0.98) indicating that the devices were likely measuring the same kind of activity.

Conclusions: Steps from Flex and Flex2 can be used interchangeably. Differences in total step count between ActiGraph and Flex devices can make cross-device comparisons of numerical step-counts challenging particularly for faster walkers.

Bove, Riley et al (2019) [Proof-of-Principle Study] Toward a low-cost, inhome, telemedicine-enabled assessment of disability in multiple sclerosis10

Background: Remote assessment of neurological disability in people with multiple sclerosis (MS) could improve access to clinical care and efficiency of clinical research. Objective: To develop and validate a telemedicine-based MS disability examination that does not require an in-home examiner.

Methods: Adults with MS were recruited after a standardized in-person Expanded Disability Status Scale (EDSS) evaluation, and within 1 week underwent a blinded televideo-enabled EDSS examination with a different clinician. EDSS and tele-EDSS scores were compared. Results: Overall, 41 adults participated (mean (standard deviation (SD)) age: 47.0 years (11.6); median EDSS: 2 (range: 0-7)); 37 required no in-home assistance for the teleEDSS evaluation (eghelp positioning camera). Mean difference between EDSS and tele-EDSS was 0.34 (95% confidence interval (CI): 0.07-0.61). For 88% of evaluations, tele-EDSS and EDSS scores were within 1 point (similar to reported in-person inter-rater differences). Unweighted kappa for agreement within 0.5 point was 0.72. Correlation for individual functional systems (FS) ranged from modest (vision: 0.37)to high (bowel/bladder: 0.79). Overall correlation between EDSS and tele-EDSS was 0.89 (p < 0.0001); and 0.98 (p < 0.0001) at EDSS range: 4-7.

Conclusion: In this proof of principle study, disability evaluation in mild to moderate MS is feasible using telemedicine without an aide at the patient’s location.

Gil-S et al (2019) [Pilot Study] Pilot study of telemedicine in multiple sclerosis to evaluate the effectiveness of a telecommunication system for the detection of the clinical activity of the disease in the number of relapses with respect to the standard clinical practice11

Objectives: The aim of this study was to measure the ability of telemedicine to detect relapses in patients with multiple sclerosis (MS); also to observe the difference between patients with cognitive impairment and cognitive preservation.

Methodology: 130 patients under treatment with firstline drugs for MS who had the computer skills to access a web platform created by this study were recruited. The patients had to answer surveys about their clinical status and were randomized in two groups: survey [intervention] and non‐ survey [control]. Also, three visits were made during the study: the basal visit, visit 6 and visit 12 months. All patients fulfilled questionnaires of mood, health, satisfaction with health services and adherence to treatment. They performed the Multiple Sclerosis Functional Composite (MSFC), and the Expanded Disability Status Scale (EDSS). The cognitive status was estimated using two tests for cognitive ability measurement: the Symbol Digit Modalities Test (SDMT) and the Paced Auditory Serial Addition Test (PASAT) and a subsequent classification was made: cognitive impairment/suspected impairment/cognitive preservation.

Results and Conclusions: The sensitivity of the platform survey was 100% and the specificity 96.5%. Both groups were equal in all the analyzed features, with the exception of the EDSS, which was significantly higher in the intervention group than in the control group (mean 0 vs. 1). There were no more relapses in the survey/intervention group (average 0 vs. 0). Patients with cognitive impairment had a worse mood at the beginning of the study and were less satisfied with the health services received than the cognitively preserved, but they showed the same adherence as them. Telemedicine is a useful tool in detecting relapses in MS patients and cognition is an important factor in the health and mood of patients with multiple sclerosis.

Shaw, Met al (2019) [Conference Abstract ]Telemedicine reaches MS patients living with disabilities: at-home telerehabilitation with remotely-supervised transcranial direct current stimulation (RS-tDCS)12

Introduction: Travel to clinic can be difficult due to barriers of time and cost and becomes even more burdensome for MS patients living with disabilities. Telemedicine platforms present a solution by providing supervised treatment and rehabilitation at home. Without barriers to access, patients may be more compliant and adherent to daily rehabilitation exercises. We have a large telerehabilitation research program in MS that pairs rehabilitation with transcranial direct current stimulation (tDCS), an emerging non-invasive brain stimulation technique used to improve outcomes. We provide real-time treatment administration and supervision via HIPAA compliant videoconference, termed remotely supervised tDCS or RS-tDCS. Objectives: To characterize the advantages of telemedicine for patients with MS in an urban setting. Aims: To measure barriers to access for participants in our RS-tDCS telerehabilitation program, as well as compliance and adherence to a remotely supervised intervention.

Methods: Participants with MS were recruited to complete a trial of cognitive remediation paired with RS-tDCS at-home. Participants were surveyed following completion of the intervention and asked to rate their difficulty in attending the clinic as well as the typical cost of attending clinic. Descriptive statistics and ordinal logistic regression models were used to evaluate the factors driving difficulty of travel.

Results: Participants (n=44) reported that round trip travel to the clinic requires an average of 2.3±2.3 hours of time and $27.04±38.13. Participants rated the difficulty associated with attending clinic as being moderate to significant (2.5±1.3). Regression analyses that included disease features produced better models and accounted for greater variance in difficulty attending the clinic, (p< 0.001, McFadden pseudo R2 = .515), as compared with socioeconomic variables alone (p< 0.001, McFadden pseudo R2 = .140). The RS-tDCS protocol was successful in providing treatment (95% compliance to treatment) and 93% of participants reported satisfaction with the treatment and remote protocols.

Conclusions: Participants with MS face considerable difficulty reaching the clinic, largely due to increasing neurologic disability. Telemedicine techniques such as RStDCS can increase treatment access, reduce physical and financial burden of travel and maintain high rates of treatment adherence. Disclosure: This pilot study was funded by the National Multiple Sclerosis Society.

Wallin, Mitchell T et al (2019) [Review] Telemedicine and Multiple Sclerosis: A Comprehensive Literature Review13

Introduction: Patients with multiple sclerosis (pwMS)face barriers accessing specialty care for evaluation and treatment. Telemedicine, the practice of clinical care at a distance with the aid of technology, may be a potential bridge to close the access gap for pwMS separated by distance or disability. The objective of this review was to investigate the types of telemedicine being utilized and overall outcomes for pwMS and their providers. Methods: A Boolean search of the medical literature was conducted between January 2000 and January 31, 2018. PubMed, EMBASE, PsycINFO and the Cochrane databases, were used to identify all relevant citations. Two reviewers independently appraised the articles for meeting study criteria and for study quality using the CASP system. Financial costs of the telemedicine applications were assessed. Results: A total of 28 studies involving 3252 participants met criteria for inclusion. Telemedicine interventions were classified, and outcomes were assessed systematically by the following categories: general MS care; rehabilitation and exercise; and neuropsychology/mental health. Studies showed a range of outcomes with variable quality. Overall, remote clinical examinations, long-term telemedicine management interventions and telerehabilitation were shown to be beneficial, cost-effective and satisfactory for patients and providers.

Discussion: Telemedicine is a viable platform for delivering specialty MS care. Remote neurological assessments and several forms of therapy have been shown to be technically feasible. Optimal implementation and barriers to the use of telemedicine in the current healthcare system should be explored.

Cohen, M. (2018) [Review] Connected health and multiple sclerosis14

There is as yet no consensual definition of connected health. In general, the term refers to the growing use of technology and, in particular, mobile technology in medicine. Over the past 10 years, there have been an increasing number of published reports on the wide-ranging and heterogeneous fields involving the application of technology in medicine, ranging from telemedicine to tools to improve patients’ evaluation and monitoring by physicians, as well as a multitude of patient-centered applications. They also represent promising tools in the field of clinical research. This report is a review of the importance of using this technology in the management of multiple sclerosis patients.

Howard, Ileana M, Kaufman, Marla S (2018) [Narrative Review]Telehealth applications for outpatients with neuromuscular or musculoskeletal disorders15

Telehealth describes the provision of medical services remotely through technology, and may enhance patient access to specialty care services. Although teleneurology has expanded widely since the introduction of telestroke in 1999, telehealth services for outpatients with neuromuscular or musculoskeletal disorders are less widespread. In this narrative review, we will describe the current technology, applications, outcomes, and limitations of this dynamically growing field. Evidence for telehealth applications related to neuromuscular diseases, palliative care, specialized multidisciplinary services, and musculoskeletal care are reviewed. With growing demand for specialized services and finite resources, telehealth provides a promising avenue to promote access to high-quality care, decrease the cost and burden of travel for patients, and with the expansion of software to personal computing and mobile devices, offer flexible, lowoverhead practice opportunities for clinicians. Providers embarking on careers in telehealth should be aware of current legal restrictions impacting care to minimize risk and avoid liability.

Lavorgna, L et al (2018)[Review] e-Health and multiple sclerosis: An update16

e-Health is becoming increasingly relevant in multiple sclerosis (MS) clinical management. We aim to review and discuss current status and future perspective of e-health in people with multiple sclerosis (pwMS). The first part of this review describes how information on MS can be conveyed through the Web and digital media. The second part illustrates recent advances in digital technology that can improve clinical management and in motor and cognitive rehabilitation of pwMS. Finally, this review advocates future development of the digital case manager as a new figure to coordinate clinical management and care of pwMS. The digital revolution is changing the medical approach to MS in terms of information conveying and sharing, rehabilitation, and healthcare management.

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