Parkinson’s disease (PD) is a chronic neurodegenerative disorder with motor symptoms like akinesia, resting tremor, skeletal muscle rigidity and postural instability, and non-motor symptoms like depression, autonomous nervous system disorders and dementia. The prevalence of PD in Japan is reported at 50 to 80 per 100,000 population, and it is increasing rapidly because Japan has become a super-ageing society. Thus, PD is expected to increase further in the future as ageing is a risk factor for developing PD.
In Japan, the high patient-to-specialist ratio limits access to proper healthcare. Willis et al. reported evidence that neurologist treatment is associated with improved patient outcomes, including survival. Although a formal cost-effectiveness analysis is beyond the scope of this report, the potential healthcare savings from simply referring patients with PD to a neurologist could be substantial. If the improved clinical outcomes and survival are confirmed in future studies, consistent neurologist care and increased neurologic education at all levels of medical training could emerge as significant disease-modifying measures.
One solution to this problem is telemedicine. The Ministry of Health, Labour and Welfare (MHLW) of Japan defines telemedicine as the provision of medical care and medical services using information and communication technology (ICT). In telemedicine, “online medicine” refers to testing and diagnostics conducted by doctors using ICT equipment, with treatment prescribed to patients in real-time. Telemedicine is effective because patients with PD and movement disorders can easily access specialists by making use of an online system.
A super-aged Japan
Japan’s society is the oldest in the world: 28.7 % of the population are 65 or older, with women forming the majority. The country is also home to a record 80 000 centenarians. By 2036, people aged 65 and over will represent a third of the population. Source: East Asia Forum
However, telemedicine has not been widely used in Japan. In fact, there is only one study on telemedicine for PD in Japan.1 Based on the evidence of the preliminary study, we started providing “online medicine” for patients with PD and related disorders using an iPad in 2017. We investigated the feasibility and safety of a video-based telemedicine system delivered via a tablet for patients with PD. In a randomised, crossover and open-label pilot trial, we compared a telemedicine period (regular visits every two months with intermediate video calls via an iPad mini) with a control period (regular visits every two months), both lasting six months. We included ten patients diagnosed with PD according to the British Brain Bank criteria. The primary outcome was the PD questionnaire summary index (PDQ-39 SI), whereas the secondary outcomes included the Hoehn and Yahr Stage and scores on the Unified PD Rating Scale (UPDRS) part I–IV, Beck Depression Inventory (BDI), and visual analogue scale for satisfaction. Both the study periods were completed by ten patients with PD. Friedman’s test revealed that there were no significant differences between the two periods in primary and secondary outcomes (p > 0.05). As for visual analogue scale scores for satisfaction, participants indicated high satisfaction with the telemedicine system. The number of extra hospital visits and phone calls did not differ between the periods. There were no adverse events or side effects either. We observed that a telemedicine system delivered via tablets could successfully be used by patients as part of their care.
In addition, we conducted a cross-sectional questionnaire survey to investigate the efficacy of using telemedicine for patients with PD and discussed the current status of telemedicine for PD in Japan before and after the COVID-19 pandemic to verify the effectiveness of telemedicine.2 Our results show that patients were satisfied with telemedicine conducted with iPads and reported that it was effective in reducing the burden of travel.
The study also shows high satisfaction with iPad-based telemedicine in the treatment of PD. This is consistent with the results of previous pilot studies, which reported high patient satisfaction with telemedicine using laptops or desktop computers and built-in carts, but even higher satisfaction with telemedicine devices such as smartphones, tablets, desktops, and laptops. Thus, the need for telemedicine has been rapidly recognised, especially after the COVID-19 pandemic, which seriously affected individuals with PD by disrupting their regular doctor visits.
Medical care for remote islands
With Microsoft HoloLens 2 (mixed reality device) and Azure Kinect DK (depth sensor), researchers at Nagasaki University in Japan developed the country’s first 3D telemedicine system for the treatment of rheumatoid arthritis, providing remote examinations for patients on remote islands in Nagasaki Prefecture from the city. Source: Screen shot of https://www.youtube.com/watch?v=j9uBXIlmJxQ
During the pandemic, telemedicine may reduce unnecessary risks of infections,3 in addition to reducing costs and time to visit the hospital.4 In fact, if the patient uses telemedicine every other month for his regular consultation, the added cost of telemedicine will be offset if the travel expense exceeds JPY 7,000. Most patients reported that telemedicine consultations were more useful than regular face-to-face visits. Among others, communicating with the doctors in a relaxed atmosphere may help one communicate efficiently. Much of the patient’s time set aside to visit the hospital can be spent consulting a doctor to discuss their problems instead of travelling. However, the current practice of telemedicine is based on two-dimensional (2D) technology, such as a video call system via laptops, desktop computers, tablets or smartphones, which limits the observation of three-dimensional (3D) movements of patients with PD. To overcome the limitations of 2D telemedicine, we proposed using the new concept of “holomedicine”, an interactive 3D hologram-based telemedicine system, which consists of RGB-depth camera sensors (Microsoft Kinect v2) that capture a person’s movements using infrared light and an augmented or mixed reality head-mounted display with a hologram monitor to project patients’ 3D images (Microsoft HoloLens)5. The system consists of two sides: the patient’s side and the physician’s side. The patient-side system captures the shape of the patient and sends that data as a digitised 3D-image to the physician via a wireless network. The physician-side system receives data from the patient-side system and reproduces the patient’s 3D-image in almost real-time using peer-to-peer networking. By using these systems in geographically distant locations, physicians can see patients in front of them as if they were sharing the same room because the screen of an augmented or mixed reality headset is spatially transparent, unlike that of a virtual reality headset.
In this system, we confirmed the feasibility of assessing patients’ motor scores via 3D telemedicine in 100 patients with PD. There was a significant correlation between the scores of the Movement Disorder Society-sponsored revision of the Unified PD Rating Scale, Part III obtained by a neurologist using the system and those measured in face-to-face evaluation (r = 0.872). Moreover, an adequate intraclass correlation coefficient (2,1) of 0.646 was obtained for these scores. This mixed reality healthcare visit could lead to an evolutionary change to the traditional consultation because it is a close approximation of an in-person visit. One of the advantages of 3D over 2D technology is that 3D technology produces a realistic atmosphere like a face-to-face visit, which may help establish additional trust between patients and doctors compared to a 2D method.
Moreover, the 3D data automatically captured and recorded during a telemedicine visit can be used for further 3D motion analysis and for machine learning or deep learning to develop an artificial intelligence (AI)-based diagnostic assistance system.6
Nonetheless, 3D telemedicine system has three issues to be resolved. First, the biggest limitation of the current 3D telemedicine system is its time and space resolution. Second, examinations that require physical contact, for example, rigidity and postural instability, are still impossible. Third, the head-mounted display may cause discomfort and potentially virtual reality sickness. However, these limitations can be addressed with technological innovations in devices, network connections such as fifth-generation (5G) cellular network technology, combined with wearable devices and future hologram technologies.
Future research should include a comparison between 3D and 2D systems. Innovative research that improves the quality and accuracy of these devices should be accelerated. Currently, the main information obtained from existing telemedicine technology using video-conferencing features based on 3D or 2D system are facial expressions and voice. The evaluation of these parameters still relies predominantly on subjective assessments. Hence, in order to improve telemedicine so that it can help assess other motor and non-motor symptoms, technologies that allow for the objective assessments of facial expressions and voice are essential. As such, we are planning to establish an objective evaluation system using AI for the advancement of telemedicine. Although telemedicine has finally taken off owing to the COVID-19 pandemic, it is important to simplify the use of devices, especially for elderly people.
PROF NOBUTAKA HATTORI
Prof Nobutaka Hattori is Chairman and Professor of Neurology at Juntendo University, Tokyo, as well as Dean of the Faculty of Medicine of Juntendo University.
He has been involved in research on molecular mechanisms of Parkinson’s disease (PD) since 1989. More recently, together with his collaborators, Prof Hattori identified the disease gene for an autosomal recessive form of young onset familial PD, and named it “parkin”. They also found that parkin was directly linked to the ubiquitin-proteasome pathway as a ubiquitin ligase. This suggested that protein degradation system is involved in the pathogenesis of not only the monogenic form of PD but also sporadic PD.
Currently, he has been investigating and developing therapeutic methods not only for PD but also other neurological diseases.
Sekimoto S., Oyama G., Hatano T. et al., A Randomized Crossover Pilot Study of Telemedicine Delivered via iPads in Parkinson's Disease. Parkinsons Dis 2019;2019:9403295. doi: 10.1155/2019/9403295 [first published online 7 February 2019].
Hollander J.E., Carr B.G., Virtually Perfect? Telemedicine for Covid-19. N Engl J Med 2020;382(18):1679-81. doi: 10.1056/NEJMp2003539 [first published online 12 March 2020].
Samii A., Ryan-Dykes P., Tsukuda R.A. et al., Telemedicine for delivery of health care in Parkinson's disease. J Telemed Telecare 2006;12(1):16-8. doi: 10.1258/135763306775321371 [first published online 28 January 2006].
Sekimoto S., Oyama G., Chiba S. et al., Holomedicine: Proof of the Concept of Interactive Three-Dimensional Telemedicine. Mov Disord 2020;35(10):1719-20. doi: 10.1002/mds.28249 [first published online 15 September 2020].
Hamaguchi T., Saito T., Suzuki M. et al., Support vector machine-based classifier for the assessment offinger movement of strokepatients undergoing rehabilitation. J Med Biol Eng 2019;40(1):91–100.