Digitizing Neurology: A Computerized Exam

Andrew N. Wilner, MD; Mark Gudesblatt, MD


March 12, 2015

Editor's Note: Medscape contributor Andrew N. Wilner, MD, recently spoke with neurologist Mark Gudesblatt, MD, about the potential benefits of computer-based neurologic assessment. What follows is their conversation.

Computerized Neurology: Introduction

Dr Wilner: Mark, you have some very interesting ideas around neurology research. Tell us what you've been working on.

Dr Gudesblatt: What we've been up to is trying to digitize, quantify, and objectify aspects of the neurologic exam having to do with patients' function. For too long we've been led by the legacy of Charcot with the physical examination to help us evaluate the impact that patients have from their disease. We use the question, "How are you?" And we use our own perceptions and examination techniques. Unfortunately, they are unreliable and insensitive to identify or objectify, and they vary from clinician to clinician, depending upon how much time and experience you have.

What we've looked at is a series of independent measures, whether it's cognition, manual dexterity, or gait and balance. What really clued us in was cognition, because in most of the clinical trials, clinicians or researchers use one simple measure, such as the PASAT (Paced Auditory Serial Addition Test) or the SDMT (Symbol Digit Modalities Test), which are paper-based tests giving only one measure of brain function. It's equivalent with Dancing With the Stars when someone says you're a 72 or an 85. I don't really know what that means anymore because I don't think you can really evaluate or quantify cognitive function, and I'll say it as a cognitive profile because some of us are stronger in verbal and some of us are stronger in math. You need a profile of individual domains of cognitive function. When we use a computerized test now, I don't have to ask them how their thinking is, and I don't have to think about how I think their thinking is. I can get a profile, and I can follow it and measure it over time to see across attention, executive function, information processing, verbal function, attention span, visuospatial, and motor skills. I can measure their profile and see where they are today, measure it in 1 month, 6 months, 1 year, 2 years, or 5 years and see how a disease unravels different aspects of their cognitive profile.

The reason why this is important is that their profile will give us an idea as to where they stand at their baseline or where they stand from age- and education-matched healthy individuals, so we can try to parse out the impact of their disease. We can do that across seven domains and a global summary score. What makes it even more powerful is the approach of bioinformatics or statistical analysis where you can take those seven domains of thinking and look across each one of them and summarize how many are more than one standard deviation away from age- and education-matched healthy individuals. What we find is something really astounding. Do you know the game KerPlunk or Break the Ice? They're kid games where you can pull out straws and see how many marbles will fall through. Well, for us, it's a question of how many straws can we pull out of brain function before the person decompensates.

It's always amazing to us that people just rapidly decompensate because we don't see that their compensatory strategies are being picked away. This allows us to do that. What we found is that when someone (with multiple sclerosis) loses three of the seven domains, their hazard ratio of being unemployed doubles. If they're physically able to drive, their hazard ratio doubles of not driving. We can now see what the thresholds are for individual diseases for unemployment and driving. I think this approach allows us not only to identify what treatments we need, but what treatments are more effective and what they're actually doing for our patients. That applies not only to cognition but also to gait, balance, fall risk, and manual dexterity. I think that this really represents a revolutionary trend—how we can quantify things.


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