Coronavirus Disease 2019 and Management of Advanced Therapies in Parkinson’s Disease; Peculiar Needs for Deep Brain Stimulation Patients? Rocco Cerroni, MD,* Simona Scalise, MD, and Alessandro Stefani, MD, PhD

We considered the review by Fasano and colleagues1 a stimulating document. The article defines a decisional algorithm on advanced therapies of Parkinson’s Diseases (PD) and addresses the clinical needs caused by the severe acute respiratory syndrome coronavirus 2 outbreak.2 To some extent, the article left open questions on possibly differential needs for each procedure. Our center, invested by coronavirus disease 2019 (COVID19) emergency, organized different modalities of health care3 and adjusted medical activity for patients with PD. To overcome the inability to perform scheduled visits (March 8 to June 3), we administered a specific survey to identify critical issues in patients with PD in device-related therapy (DrT). Of the 54 patients with PD in DrT interviewed, 21 were treated with deep brain stimulation (DBS) onto the subthalamic nucleus (1–5 years previously), 32 were on levodopa–carbidopa intestinal gel therapy and (for at least 18 months), and 2 were in continuous subcutaneous apomorphine infusion. The interview was structured in 1 parts: the first investigated symptoms and any COVID-19-related diagnostic processes, the presence of epidemic-related concerns, and precautionary measures taken by patients; the second part evaluated the presence of motor/nonmotor worsening and the impact of the severe acute respiratory syndrome coronavirus 2 outbreak on DrT. We studied the possible clinical deterioration requiring a device adjustment, the possibility of remote intervention, and finally, if the COVID-19 emergency changed the patients’ relationships with the device. Our survey suggests that there are substantial differences between different DrT. Among the 32 patients on levodopa– carbidopa intestinal gel, only 4 required an active intervention on the pump consisting of a dosage modulation, successfully performed using a smartphone video call with the help of a

caregiver (Video S1). No urgency was found in 2 patients on apomorphine (such a small number does not allow any inference). Conversely, DBS patients presented greater difficulties (6 of 21). Two required a large increase in the levodopa daily dosage (>20%) in the absence of significant worsening of motor performance as judged by smartphone video call; a similar event had never occurred during their prolonged clinical history, probably implying a sort of “nocebo effect” related to the lack of empathic interaction with clinicians and to the reduced possibility of intervention on the device. Two patients developed an anxiety disorder with a false belief of low battery that could not be resolved by remote intervention and that required dedicated access to our clinic in a clean dedicated path. Finally, 2 patients dissatisfied with their motor condition independently increased the levodopa intake with the unmasking of dyskinesias otherwise controlled until then. Preliminary survey analysis shows that patients on levodopa– carbidopa intestinal gel maintained good confidence in DrT; nevertheless, patients with DBS, while acknowledging that without DBS they would be worsened, accrued a greater mistrust toward their therapy. DBS therapy requires special attention during a crisis when routine personnel dedicated to psychological interventions or rehabilitation practices are not available. Developing dedicated clinical pathways for patients with DBS is extremely important, considering the possible psychopathological vulnerability and the relevance of the placebo/nocebo-effect. To this aim, it is necessary to implement telemedicine tools that allow large-scale remote intervention with patients with DBS,4,5 knowingly taking into account that patients with PD in DrT are not a homogeneous cohort.■

Department of System Medicine, UOSD Parkinson, University of Rome "Tor Vergata", Rome, Italy *Correspondence to: Rocco Cerroni, Department of System Medicine, UOSD Parkinson, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy; E-mail: [email protected] Keywords: COVID-19, Italy, DBS, LCIG, Parkinson’s disease. Received 25 June 2020; accepted 13 July 2020. Published online 00 Month 2020 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mdc3.13033

MOVEMENT DISORDERS CLINICAL PRACTICE 2020. doi: 10.1002/mdc3.13033 © 2020 International Parkinson and Movement Disorder Society




Author Roles


(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique. R.C.: 1A, 1B, 1C, 2B, 2C, 3A, 3B S.S.: 1A,1B, 1C, 2C, 3B, 2C A.S.: 1A, 1B, 2C, 2A, 2C, 3B

1. Fasano A, Antonini A, Katzenschlager R, et al. Management of advanced therapies in Parkinson’s disease patients in times of humanitarian crisis: the COVID-19 experience. Mov Disord Clin Pract 2020;7(4):361–372. 2. Montalvan V, Lee J, Bueso T, De Toledo J, Rivas K. Neurological manifestations of COVID-19 and other coronavirus infections: a systematic review. Clin Neurol Neurosurg 2020;194:105921. 3. Schirinzi T, Cerroni R, Di Lazzaro G, et al. Self-reported needs of patients with Parkinson’s disease during COVID-19 emergency in Italy. Neurol Sci 2020;41(6):1373–1375. 4. ANZCTR. Remote Care for patients with Parkinson’s disease implanted with deep brain stimulation devices: A safety and feasibility Study. https:// www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378612.

Disclosures Ethical Compliance Statement: The Independent Ethics Committee of Fondazione Policlinico Tor Vergata (Viale Oxford, 81–00133 Rome, Italy) approved the study. The authors confirm that patient consent was not required for this work. Authors obtained informed consent for the smartphone video call publication. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. Funding Sources and Conflict of Interest: This study was conducted without founding sources, and Rocco Cerroni, Simona Scalise, and Alessandro Stefani have no conflicts of interest. Financial Disclosures for the Previous 12 Months: Rocco Cerroni and Simona Scalise report no disclosures for the previous 12 months. Alessandro Stefani received honoraria from Abbvie, Medtronic, and Zambon.


5. Seritan AL, Heiry M, Iosif AM, Dodge M, Ostrem JL. Telepsychiatry for patients with movement disorders: a feasibility and patient satisfaction study. J Clin Mov Disord 2019;6:1.

Supporting Information Supporting information may be found in the online version of this article. Video S1. Two cases of remote monitoring in 2 patients with PD treated with levodopa–carbidopa intestinal gel using a smartphone video call during the coronavirus disease 2019 lockdown in Italy. Segment 1: remote clinical monitoring in a patient (patient 1) in therapy with levodopa–carbidopa intestinal gel showing an acceptable clinical compensation. Segment 2: remote clinical monitoring and dosage adjustment with the help of caregiver in a patient with PD (patient 2) suffering from troublesome dyskinesia. Video was performed by a screen registration during the call and is without audio.

MOVEMENT DISORDERS CLINICAL PRACTICE 2020. doi: 10.1002/mdc3.13033

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