Implementation of Mobile Health Technologies in Clinical Trials of Movement Disorders: Underutilized Potential

Wearable devices for gait and posture monitoring via telemedicine in people with movement disorders and multiple sclerosis: a systematic review

INTRODUCTION

Wearable devices and telemedicine are increasingly used to track health-related parameters across patient populations. Since gait and postural control deficits contribute to mobility deficits in persons with movement disorders and multiple sclerosis, we thought it interesting to evaluate devices in telemedicine for gait and posture monitoring in such patients.

METHODS

For this systematic review, we searched the electronic databases MEDLINE (PubMed), SCOPUS, Cochrane Library, and SPORTDiscus. Of the 452 records retrieved, 12 met the inclusion/exclusion criteria. Data about (1) study characteristics and clinical aspects, (2) technical, and (3) telemonitoring and teleconsulting were retrieved, The studies were quality assessed.

RESULTS

All studies involved patients with Parkinson's disease; most used triaxial accelerometers for general assessment (n = 4), assessment of motor fluctuation (n = 3), falls (n = 2), and turning (n = 3). Sensor placement and count varied widely across studies. Nine used lab-validated algorithms for data analysis. Only one discussed synchronous patient feedback and asynchronous teleconsultation.

CONCLUSIONS

Wearable devices enable real-world patient monitoring and suggest biomarkers for symptoms and behaviors related to underlying gait disorders. thus enriching clinical assessment and personalized treatment plans. As digital healthcare evolves, further research is needed to enhance device accuracy, assess user acceptability, and integrate these tools into telemedicine infrastructure.

PROSPERO REGISTRATION

CRD42022355460.

EFAS/EAN survey on the influence of the COVID-19 pandemic on European clinical autonomic education and research

PURPOSE

To understand the influence of the coronavirus disease 2019 (COVID-19) pandemic on clinical autonomic education and research in Europe.

METHODS

We invited 84 European autonomic centers to complete an online survey, recorded the pre-pandemic-to-pandemic percentage of junior participants in the annual congresses of the European Federation of Autonomic Societies (EFAS) and European Academy of Neurology (EAN) and the pre-pandemic-to-pandemic number of PubMed publications on neurological disorders.

RESULTS

Forty-six centers answered the survey (55%). Twenty-nine centers were involved in clinical autonomic education and experienced pandemic-related didactic interruptions for 9 (5; 9) months. Ninety percent (n = 26/29) of autonomic educational centers reported a negative impact of the COVID-19 pandemic on education quality, and 93% (n = 27/29) established e-learning models. Both the 2020 joint EAN-EFAS virtual congress and the 2021 (virtual) and 2022 (hybrid) EFAS and EAN congresses marked higher percentages of junior participants than in 2019. Forty-one respondents (89%) were autonomic researchers, and 29 of them reported pandemic-related trial interruptions for 5 (2; 9) months. Since the pandemic begin, almost half of the respondents had less time for scientific writing. Likewise, the number of PubMed publications on autonomic topics showed the smallest increase compared with other neurological fields in 2020-2021 and the highest drop in 2022. Autonomic research centers that amended their trial protocols for telemedicine (38%, n = 16/41) maintained higher clinical caseloads during the first pandemic year.

CONCLUSIONS

The COVID-19 pandemic had a substantial negative impact on European clinical autonomic education and research. At the same time, it promoted digitalization, favoring more equitable access to autonomic education and improved trial design.

Objective measurement versus clinician-based assessment for Parkinson's disease

INTRODUCTION

Although clinician-based assessment through standardized clinical rating scales is currently the gold standard for quantifying motor impairment in Parkinson's disease (PD), it is not without limitations, including intra- and inter-rater variability and a degree of approximation. There is increasing evidence supporting the use of objective motion analyses to complement clinician-based assessment. Objective measurement tools hold significant potential for improving the accuracy of clinical and research-based evaluations of patients.

AREAS COVERED

The authors provide several examples from the literature demonstrating how different motion measurement tools, including optoelectronics, contactless and wearable systems allow for both the objective quantification and monitoring of key motor symptoms (such as bradykinesia, rigidity, tremor, and gait disturbances), and the identification of motor fluctuations in PD patients. Furthermore, they discuss how, from a clinician's perspective, objective measurements can help in various stages of PD management.

EXPERT OPINION

In our opinion, sufficient evidence supports the assertion that objective monitoring systems enable accurate evaluation of motor symptoms and complications in PD. A range of devices can be utilized not only to support diagnosis but also to monitor motor symptom during the disease progression and can become relevant in the therapeutic decision-making process.

Toward objective monitoring of Parkinson's disease motor symptoms using a wearable device: wearability and performance evaluation of PDMonitor®

Parkinson's disease (PD) is characterized by a variety of motor and non-motor symptoms. As disease progresses, fluctuations in the response to levodopa treatment may develop, along with emergence of freezing of gait (FoG) and levodopa induced dyskinesia (LiD). The optimal management of the motor symptoms and their complications, depends, principally, on the consistent detection of their course, leading to improved treatment decisions. During the last few years, wearable devices have started to be used in the clinical practice for monitoring patients' PD-related motor symptoms, during their daily activities. This work describes the results of 2 multi-site clinical studies (PDNST001 and PDNST002) designed to validate the performance and the wearability of a new wearable monitoring device, the PDMonitor^®, in the detection of PD-related motor symptoms. For the studies, 65 patients with Parkinson's disease and 28 healthy individuals (controls) were recruited. Specifically, during the Phase I of the first study, participants used the monitoring device for 2-6 h in a clinic while neurologists assessed the exhibited parkinsonian symptoms every half hour using the Unified Parkinson's Disease Rating Scale (UPDRS) Part III, as well as the Abnormal Involuntary Movement Scale (AIMS) for dyskinesia severity assessment. The goal of Phase I was data gathering. On the other hand, during the Phase II of the first study, as well as during the second study (PDNST002), day-to-day variability was evaluated, with patients in the former and with control subjects in the latter. In both cases, the device was used for a number of days, with the subjects being unsupervised and free to perform any kind of daily activities. The monitoring device produced estimations of the severity of the majority of PD-related motor symptoms and their fluctuations. Statistical analysis demonstrated that the accuracy in the detection of symptoms and the correlation between their severity and the expert evaluations were high. As a result, the studies confirmed the effectiveness of the system as a continuous telemonitoring solution, easy to be used to facilitate decision-making for the treatment of patients with Parkinson's disease.

Mapping Relevance of Digital Measures to Meaningful Symptoms and Impacts in Early Parkinson's Disease

BACKGROUND

Adoption of new digital measures for clinical trials and practice has been hindered by lack of actionable qualitative data demonstrating relevance of these metrics to people with Parkinson's disease.

OBJECTIVE

This study evaluated of relevance of WATCH-PD digital measures to meaningful symptoms and impacts of early Parkinson's disease from the patient perspective.

METHODS

Participants with early Parkinson's disease (N = 40) completed surveys and 1:1 online-interviews. Interviews combined: 1) symptom mapping to delineate meaningful symptoms/impacts of disease, 2) cognitive interviewing to assess content validity of digital measures, and 3) mapping of digital measures back to personal symptoms to assess relevance from the patient perspective. Content analysis and descriptive techniques were used to analyze data.

RESULTS

Participants perceived mapping as deeply engaging, with 39/40 reporting improved ability to communicate important symptoms and relevance of measures. Most measures (9/10) were rated relevant by both cognitive interviewing (70-92.5%) and mapping (80-100%). Two measures related to actively bothersome symptoms for more than 80% of participants (Tremor, Shape rotation). Tasks were generally deemed relevant if they met three participant context criteria: 1) understanding what the task measured, 2) believing it targeted an important symptom of PD (past, present, or future), and 3) believing the task was a good test of that important symptom. Participants did not require that a task relate to active symptoms or "real" life to be relevant.

CONCLUSION

Digital measures of tremor and hand dexterity were rated most relevant in early PD. Use of mapping enabled precise quantification of qualitative data for more rigorous evaluation of new measures.

Real-life ankle submovements and computer mouse use reflect patient-reported function in adult ataxias

Novel disease-modifying therapies are being evaluated in spinocerebellar ataxias and multiple system atrophy. Clinician-performed disease rating scales are relatively insensitive for measuring disease change over time, resulting in large and long clinical trials. We tested the hypothesis that sensors worn continuously at home during natural behaviour and a web-based computer mouse task performed at home could produce interpretable, meaningful and reliable motor measures for potential use in clinical trials. Thirty-four individuals with degenerative ataxias (spinocerebellar ataxia types 1, 2, 3 and 6 and multiple system atrophy of the cerebellar type) and eight age-matched controls completed the cross-sectional study. Participants wore an ankle and wrist sensor continuously at home for 1 week and completed the Hevelius computer mouse task eight times over 4 weeks. We examined properties of motor primitives called 'submovements' derived from the continuous wearable sensors and properties of computer mouse clicks and trajectories in relationship to patient-reported measures of function (Patient-Reported Outcome Measure of Ataxia) and ataxia rating scales (Scale for the Assessment and Rating of Ataxia and the Brief Ataxia Rating Scale). The test-retest reliability of digital measures and differences between ataxia and control participants were evaluated. Individuals with ataxia had smaller, slower and less powerful ankle submovements during natural behaviour at home. A composite measure based on ankle submovements strongly correlated with ataxia rating scale scores (Pearson's r = 0.82-0.88), strongly correlated with self-reported function (r = 0.81), had high test-retest reliability (intraclass correlation coefficient = 0.95) and distinguished ataxia and control participants, including preataxic individuals (n = 4) from controls. A composite measure based on computer mouse movements and clicks strongly correlated with ataxia rating scale total (r = 0.86-0.88) and arm scores (r = 0.65-0.75), correlated well with self-reported function (r = 0.72-0.73) and had high test-retest reliability (intraclass correlation coefficient = 0.99). These data indicate that interpretable, meaningful and highly reliable motor measures can be obtained from continuous measurement of natural movement, particularly at the ankle location, and from computer mouse movements during a simple point-and-click task performed at home. This study supports the use of these two inexpensive and easy-to-use technologies in longitudinal natural history studies in spinocerebellar ataxias and multiple system atrophy of the cerebellar type and shows promise as potential motor outcome measures in interventional trials.

Digital Phenotyping in Clinical Neurology

Internet-connected devices, including personal computers, smartphones, smartwatches, and voice assistants, have evolved into powerful multisensor technologies that billions of people interact with daily to connect with friends and colleagues, access and share information, purchase goods, play games, and navigate their environment. Digital phenotyping taps into the data streams captured by these devices to characterize and understand health and disease. The purpose of this article is to summarize opportunities for digital phenotyping in neurology, review studies using everyday technologies to obtain motor and cognitive information, and provide a perspective on how neurologists can embrace and accelerate progress in this emerging field.

Acceptability of an In-Home Multimodal Sensor Platform in Parkinson’s Disease: A Qualitative Study (Preprint)

Background

Parkinson disease (PD) symptoms are complex, gradually progressive, and fluctuate hour by hour. Home-based technological sensors are being investigated to measure symptoms and track disease progression. A smart home sensor platform, with cameras and wearable devices, could be a useful tool to use to get a fuller picture of what someone’s symptoms are like. High-resolution video can capture the ground truth of symptoms and activities. There is a paucity of information about the acceptability of such sensors in PD.

Objective

The primary objective of our study was to explore the acceptability of living with a multimodal sensor platform in a naturalistic setting in PD. Two subobjectives are to identify any suggested limitations and to explore the sensors’ impact on participant behaviors.

Methods

A qualitative study was conducted with an inductive approach using semistructured interviews with a cohort of PD and control participants who lived freely for several days in a home-like environment while continuously being sensed.

Results

This study of 24 participants (12 with PD) found that it is broadly acceptable to use multimodal sensors including wrist-worn wearables, cameras, and other ambient sensors passively in free-living in PD. The sensor that was found to be the least acceptable was the wearable device. Suggested limitations on the platform for home deployment included camera-free time and space. Behavior changes were noted by the study participants, which may have related to being passively sensed. Recording high-resolution video in the home setting for limited periods of time was felt to be acceptable to all participants.

Conclusions

The results broaden the knowledge of what types of sensors are acceptable for use in research in PD and what potential limitations on these sensors should be considered in future work. The participants’ reported behavior change in this study should inform future similar research design to take this factor into account. Collaborative research study design, involving people living with PD at every stage, is important to ensure that the technology is acceptable and that the data outcomes produced are ecologically valid and accurate.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2020-041303

Complex motion series performance differs between previously untreated patients with Parkinson's disease and controls

Motor behaviour in patients with Parkinson's disease is determined with instrumental tests and rating procedures. Results mirror impairment of an individual patient. Objectives were to determine the associations between two kinds of motion series and rating scores in previously untreated 64 patients and to compare outcomes to controls. The line tracing task asks to follow a given path. It measures the needed interval, the number and duration of contacts to the path. The aiming procedure asks to hit contact plates with a pencil and determines the needed time period and the number of accurate, respectively, missed key strokes. Both tests differed between patients and controls. The line tracing task was more sensitive. The line tracing task asks for a complex motion series performance with more cognitive load. The aiming task prompts for a conduction of preponderant simple, repetitive movement series. Only initially, a complex process of aiming is necessary. Performance of complex motion sequences better differs between patients with Parkinson's disease and controls than conduction of simple, repetitive movement series.

Digital Therapeutics in Parkinson's Disease: Practical Applications and Future Potential

Digital therapeutics, treatments delivered remotely and enabled by modern technology, facilitate the provision of personalized, evidence-based, interdisciplinary interventions to manage the complexities associated with Parkinson’s disease. In the context of the COVID-19 pandemic, the need for digital therapeutics has arguably never been greater. However, despite new advances in technology and a heightened interest due to the pandemic, digital therapeutics remain underdeveloped and underutilized. In this paper, we briefly review practical applications and emerging advances in digital therapeutic platforms that target motor and non-motor signs and healthy lifestyle behaviors such as regular exercise, a healthful diet and optimal sleep hygiene habits. Future applications which could transform personalized self-management and patient care are presented. Opportunities, drawbacks and barriers to access are discussed.

Protocol for PD SENSORS: Parkinson's Disease Symptom Evaluation in a Naturalistic Setting producing Outcome measuRes using SPHERE technology. An observational feasibility study of multi-modal multi-sensor technology to measure symptoms and activities of daily living in Parkinson's disease

INTRODUCTION

The impact of disease-modifying agents on disease progression in Parkinson's disease is largely assessed in clinical trials using clinical rating scales. These scales have drawbacks in terms of their ability to capture the fluctuating nature of symptoms while living in a naturalistic environment. The SPHERE (Sensor Platform for HEalthcare in a Residential Environment) project has designed a multi-sensor platform with multimodal devices designed to allow continuous, relatively inexpensive, unobtrusive sensing of motor, non-motor and activities of daily living metrics in a home or a home-like environment. The aim of this study is to evaluate how the SPHERE technology can measure aspects of Parkinson's disease.

METHODS AND ANALYSIS

This is a small-scale feasibility and acceptability study during which 12 pairs of participants (comprising a person with Parkinson's and a healthy control participant) will stay and live freely for 5 days in a home-like environment embedded with SPHERE technology including environmental, appliance monitoring, wrist-worn accelerometry and camera sensors. These data will be collected alongside clinical rating scales, participant diary entries and expert clinician annotations of colour video images. Machine learning will be used to look for a signal to discriminate between Parkinson's disease and control, and between Parkinson's disease symptoms 'on' and 'off' medications. Additional outcome measures including bradykinesia, activity level, sleep parameters and some activities of daily living will be explored. Acceptability of the technology will be evaluated qualitatively using semi-structured interviews.

ETHICS AND DISSEMINATION

Ethical approval has been given to commence this study; the results will be disseminated as widely as appropriate.

Modernizing Daily Function Assessment in Parkinson's Disease Using Capacity, Perception, and Performance Measures

Many disease symptoms restrict the quality of life of the affected. This usually occurs indirectly, at least in most neurological diseases. Here, impaired daily function is interposed between the symptoms and the reduced quality of life. This is reflected in the International Classification of Function, Disability and Health model published by the World Health Organization in 2001. This correlation between symptom, daily function, and quality of life makes it clear that to evaluate the success of a therapy and develop new therapies, daily function must also be evaluated as accurately as possible. However, daily function is a complex construct and therefore difficult to quantify. To date, daily function has been measured primarily by capacity (clinical assessments) and perception (surveys and patient-reported outcomes) assessment approaches. Now, daily function can be captured in a new dimension, that is, performance, through new digital technologies that can be used in the home environment of patients. This viewpoint discusses the differences and interdependencies of capacity, perception, and performance assessment types using the example of Parkinson's disease. Options regarding how future study protocols should be designed to get the most comprehensive and validated picture of daily function in patients are presented. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.