Capturing nighttime symptoms in Parkinson disease: Technical development and experimental verification of inertial sensors for nocturnal hypokinesia

Old problems, new solutions: harnessing technology and innovation in Parkinson's disease-evidence and experiences from Thailand

The prevalence of Parkinson's disease (PD) is increasing rapidly worldwide, but there are notable inequalities in its distribution and in the availability of healthcare resources across different world regions. Low- and middle-income countries (LMICs), including Thailand, bear the highest burden of PD so there is an urgent need to develop effective solutions that can overcome the many regional challenges associated with delivering high-quality, and equitable care to a diverse population with limited resources. This article describes the evolution of healthcare delivery for PD in Thailand, as a case example of a LMIC. The discussions reflect the author's presentation at the Yoshikuni Mizuno Lectureship Award given during the 8th Asian and Oceanian Parkinson's Disease and Movement Disorders Congress in March 2023 for which he was the 2023 recipient. The specific challenges faced in Thailand are reviewed along with new solutions that have been implemented to improve the knowledge and skills of healthcare professionals nationally, the delivery of care, and the outcomes for PD patients. Technology and innovation have played an important role in this process with many new tools and devices being implemented in clinical practice. Without any realistic prospect of a curative therapy in the near future that could halt the current PD pandemic, it will be necessary to focus on preventative lifestyle strategies that can help reduce the risk of developing PD such as good nutrition (EAT), exercise (MOVE), good sleep hygiene (SLEEP), and minimizing environmental risks (PROTECT), which should be initiated and continued (REPEAT) as early as possible.

Too little or too much nocturnal movements in Parkinson's disease: A practical guide to managing the unseen

Nocturnal and sleep-related motor disorders in people with Parkinson's disease (PD) have a wide spectrum of manifestations and present a complex clinical picture. Problems can arise due to impaired movement ability (hypokinesias), e.g. nocturnal hypokinesia or early-morning akinesia, or to excessive movement (hyperkinesias), e.g. end-of-the-day dyskinesia, parasomnias, periodic limb movement during sleep and restless legs syndrome. These disorders can have a significant negative impact on the sleep, daytime functional ability, and overall quality of life of individuals with PD and their carers. The debilitating motor issues are often accompanied by a combination of non-motor symptoms, including pain and cramping, which add to the overall burden. Importantly, nocturnal motor disorders encompass a broader timeline than just the period of sleep, often starting in the evening, as well as occurring throughout the night and on awakening, and are not just limited to problems of insomnia or sleep fragmentation. Diagnosis can be challenging as, in many cases, the 'gold standard' assessment method is video polysomnography, which may not be available in all settings. Various validated questionnaires are available to support evaluation, and alternative approaches, using wearable sensors and digital technology, are now being developed to facilitate early diagnosis and monitoring. This review sets out the parameters of what can be considered normal nocturnal movement and describes the clinical manifestations, usual clinical or objective assessment methods, and evidence for optimal management strategies for the common nocturnal motor disorders that neurologists will encounter in people with PD in their clinical practice.

The rise of Parkinson's disease is a global challenge, but efforts to tackle this must begin at a national level: a protocol for national digital screening and "eat, move, sleep" lifestyle interventions to prevent or slow the rise of non-communicable diseases in Thailand

The rising prevalence of Parkinson's disease (PD) globally presents a significant public health challenge for national healthcare systems, particularly in low-to-middle income countries, such as Thailand, which may have insufficient resources to meet these escalating healthcare needs. There are also many undiagnosed cases of early-stage PD, a period when therapeutic interventions would have the most value and least cost. The traditional "passive" approach, whereby clinicians wait for patients with symptomatic PD to seek treatment, is inadequate. Proactive, early identification of PD will allow timely therapeutic interventions, and digital health technologies can be scaled up in the identification and early diagnosis of cases. The Parkinson's disease risk survey (TCTR20231025005) aims to evaluate a digital population screening platform to identify undiagnosed PD cases in the Thai population. Recognizing the long prodromal phase of PD, the target demographic for screening is people aged ≥ 40 years, approximately 20 years before the usual emergence of motor symptoms. Thailand has a highly rated healthcare system with an established universal healthcare program for citizens, making it ideal for deploying a national screening program using digital technology. Designed by a multidisciplinary group of PD experts, the digital platform comprises a 20-item questionnaire about PD symptoms along with objective tests of eight digital markers: voice vowel, voice sentences, resting and postural tremor, alternate finger tapping, a "pinch-to-size" test, gait and balance, with performance recorded using a mobile application and smartphone's sensors. Machine learning tools use the collected data to identify subjects at risk of developing, or with early signs of, PD. This article describes the selection and validation of questionnaire items and digital markers, with results showing the chosen parameters and data analysis methods to be robust, reliable, and reproducible. This digital platform could serve as a model for similar screening strategies for other non-communicable diseases in Thailand.

Assessing impaired bed mobility in patients with Parkinson's disease: a scoping review

BACKGROUND

Although most patients with Parkinson's disease (PD) experience difficulties in bed mobility, evidence on the suitability of the methods for assessing impaired bed mobility in PD are lacking.

OBJECTIVES

To identify objective methods for assessing impaired bed mobility in PD and to discuss their clinimetric properties and feasibility for use in clinical practice.

DATA SOURCES

PubMed, Web of Science, and Cochrane Library were searched between 1995 and 2022.

SELECTION CRITERIA

Studies were included if they described an objective assessment method for assessing impaired bed mobility in PD.

DATA EXTRACTION AND DATA SYNTHESIS

Characteristics of the identified measurement methods such as clinimetric properties and feasibility were extracted by two authors. The methodological quality of studies was evaluated using the Appraisal of studies tool.

RESULTS

Twenty-three studies were included and categorised into three assessment methods: sensor-based assessments (48%), rating scales (39%), and timed-tests (13%). The risk of bias was low for all but one study, which was medium.

LIMITATIONS

Despite applying wide selection criteria, a relatively small number of studies were identified in our results.

CONCLUSION

Rating scales may be the most preferred for assessing impaired bed mobility in PD in clinical practice, until clinimetric validity are adequately demonstrated in the other assessment methods. CONTRIBUTION OF PAPER.

Measurement instruments to assess basic functional mobility in Parkinson's Disease: A systematic review of clinimetric properties and feasibility for use in clinical practice

Taniguchi S, Yamamoto A. Measurement instruments to assess basic functional mobility in Parkinson's Disease: A systematic review of clinimetric properties and feasibility for use in clinical practice. Jpn J Compr Rehabil Sci 2023; 14: 16-25.

Objective

To systematically review the evaluation of clinimetric properties and feasibility of the "Modified Parkinson Activity Scale (M-PAS)" and the "Lindop Parkinson's Disease Mobility Assessment (LPA)," which are Parkinson's Disease (PD)-specific measurement instruments to assess basic functional mobility, and to discuss their considerations for use in clinical practice.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A risk of bias assessment was also performed.

Results

Eleven studies were included: five studies used M-PAS (45%), five studies used LPA (45%), and one study used M-PAS and LPA (13%). The risk of bias was low for all evaluated studies.

Conclusion

M-PAS and LPA showed adequate reliability, validity, and responsiveness in detecting intervention changes. M-PAS has more detailed qualitative scoring options, a lack of ceiling effect, and can be used by a non-expert in PD.In contrast, the drawback of M-PAS is that it is time-consuming to apply in everyday clinical practice. On the other hand, LPA with greater simplicity may lead to lower burdens for both patients and raters in situations with strict time limitations. Further research is required to identify new resources.

Technological evaluation of strategies to get out of bed by people with Parkinson's disease: Insights from multisite wearable sensors

Background

Difficulty getting out of bed is a common night-time and early morning manifestation of Parkinson's disease (PD), rated by 40% of the patients as their most concerning motor symptoms. However, current assessment methods are based on clinical interviews, video analysis, and clinical scales as objective outcome measures are not yet available.

Objective

To study the technical feasibility of multisite wearable sensors in the assessment of the supine-to-stand (STS) task as a determinant of the ability to get out of bed in patients with PD and age-matched control subjects, and develop relevant objective outcome measures.

Methods

The STS task was assessed in 32 patients with PD (mean Hoehn and Yahr; HY = 2.5) in the early morning before their first dopaminergic medication, and in 14 control subjects, using multisite wearable sensors (NIGHT-Recorder®; trunk, both wrists, and both ankles) in a sleep laboratory. Objective getting out of bed parameters included duration, onset, velocity and acceleration of truncal rotation, and angle deviation (a°) from the z-axis when subjects rose from the bed at different angles from the x-axis (10°, 15°, 30°, 45°, and 60°) as measures of truncal lateral flexion. Movement patterns were identified from the first body part or parts that moved. Correlation analysis was performed between these objective outcomes and standard clinical rating scales.

Results

Compared to control subjects, the duration of STS was significantly longer in patients with PD (p = 0.012), which is associated with a significantly slower velocity of truncal rotation (p = 0.003). Moderate and significant correlations were observed between the mean STS duration and age, and the Nocturnal Hypokinesia Questionnaire. The velocity of truncal rotation negatively and significantly correlated with HY staging. Any arm and leg moved together as the first movement significantly correlated with UPDRS-Axial and item #28. Several other correlations were also observed.

Conclusion

Our study was able to demonstrate the technical feasibility of using multisite wearable sensors to quantitatively assess early objective outcome measures of the ability of patients with PD to get out of bed, which significantly correlated with axial severity scores, suggesting that axial impairment could be a contributing factor in difficulty getting out of bed. Future studies are needed to refine these outcome measures for use in therapeutic trials related to nocturia or early morning akinesia in PD.

Determinants of impaired bed mobility in Parkinson’s disease: Impact of hip muscle strength and motor symptoms

BACKGROUND: Although most patients with Parkinson’s disease (PD) present difficulties of bed mobility, the contributing factors to impaired bed mobility in PD are unknown. OBJECTIVE: To compare bed mobility and muscle strength between PD patients and healthy controls, and investigate the determinants of bed mobility in PD. METHODS: Sixteen patients with PD and ten age- and sex-matched healthy controls (HC) were enrolled. Time and pattern to get out of bed to their preferred side at usual speed, muscle torque in lower extremities and motor symptom burden were also measured. RESULTS: PD exhibited significantly slower speed in bed mobility and lower torque in the hip adductor/abductor/flexor muscle than HC. Slower movement time in PD was correlated with weaker hip adductor torque on the more affected side (Rs = –0.56, p < 0.05) and with higher score in arm rigidity both sides (Rs≥0.79, p < 0.01). There were no significant differences between the categorised movement patterns and movement time in PD (p = 0.31). CONCLUSIONS: Reduced hip adductors torque and severe arm rigidity are associated with slowness of getting out of bed, implying that these components could be used as targets for rehabilitation practice to improve bed mobility in PD.

Wearables in the home-based assessment of abnormal movements in Parkinson's disease: a systematic review of the literature

At present, the standard practices for home-based assessments of abnormal movements in Parkinson's disease (PD) are based either on subjective tools or on objective measures that often fail to capture day-to-day fluctuations and long-term information in real-life conditions in a way that patient's compliance and privacy are secured. The employment of wearable technologies in PD represents a great paradigm shift in healthcare remote diagnostics and therapeutics monitoring. However, their applicability in everyday clinical practice seems to be still limited. We carried out a systematic search across the Medline Database. In total, 246 publications, published until 1 June 2020, were identified. Among them, 26 reports met the inclusion criteria and were included in the present review. We focused more on clinically relevant aspects of wearables' application including feasibility and efficacy of the assessment, the number, type and body position of the wearable devices, type of PD motor symptom, environment and duration of assessments and validation methodology. The aim of this review is to provide a systematic overview of the current knowledge and state-of-the-art of the home-based assessment of motor symptoms and fluctuations in PD patients using wearable technology, highlighting current problems and laying foundations for future works.

Effects of Levodopa on quality of sleep and nocturnal movements in Parkinson's Disease

BACKGROUND

Sleep disturbances are common in Parkinson's Disease (PD), with nocturnal akinesia being one of the most burdensome. Levodopa is frequently used in clinical routine to improve nocturnal akinesia, although evidence is not well proven.

METHODS

We assessed associations of Levodopa intake with quality of sleep and perception of nocturnal akinesia in three PD cohorts, using the Parkinson's Disease Sleep Scale (PDSS-2) in two cohorts and a question on nocturnal immobility in one cohort. In one cohort also objective assessment of mobility during sleep was performed, using mobile health technology.

RESULTS

In an independent analysis of all three cohorts (in total n = 1124 PD patients), patients taking Levodopa CR reported a significantly higher burden by nocturnal akinesia than patients without Levodopa. Higher Levodopa intake and MDS-UPDRS part IV scores (indicating motor fluctuations) predicted worse PDSS-2 and higher subjective nocturnal immobility scores, while disease duration and severity were not predictive. Levodopa intake was not associated with objectively changed mobility during sleep.

CONCLUSION

Our results showed an association of higher Levodopa intake with perception of worse quality of sleep and nocturnal immobility in PD, indicating that Levodopa alone might not be suitable to improve subjective feeling of nocturnal akinesia in PD. In contrast, Levodopa intake was not relevantly associated with objectively measured mobility during sleep. PD patients with motor fluctuations may be particularly affected by subjective perception of nocturnal mobility. This study should motivate further pathophysiological and clinical investigations on the cause of perception of immobility during sleep in PD.

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

Mobile health technologies (mHealth) are patient-worn or portable devices aimed at increasing the granularity and relevance of clinical measurements. The implementation of mHealth has the potential to decrease sample size, duration, and cost of clinical trials. We performed a review of the ClinicalTrials.gov database using a standardized approach to identify adoption in and usefulness of mHealth in movement disorders interventional clinical trials. Trial phase, geographical area, availability of data captured, constructs of interest, and outcome priority were collected. Eligible trials underwent quality appraisal using an ad hoc 5-point checklist to assess mHealth feasibility, acceptability, correlation with patient-centered outcome measures, and clinical meaningfulness. A total of 29% (n = 54/184) registered trials were using mHealth, mainly in Parkinson's disease and essential tremor (59.3% and 27.8%). In most cases, mHealth were used in phase 2 trials (83.3%) as secondary outcome measures (59.3%). Only five phase 3 trials, representing 9.3% of the total, used mHealth (1 as primary outcome measure, 3 as secondary, and 1 as tertiary). Only 3.7% (n = 2/54) of all trials used mHealth for measuring both motor and non-motor symptoms, and 23.1% (n = 12/52) used mHealth for unsupervised, ecologic outcomes. Our findings suggest that mHealth remain underutilized and largely relegated to phase 2 trials for secondary or tertiary outcome measures. Efforts toward greater alignment of mHealth with patient-centered outcomes and development of a universal, common-language platform to synchronize data from one or more devices will assist future efforts toward the integration of mHealth into clinical trials.

Shedding Light on Nocturnal Movements in Parkinson's Disease: Evidence from Wearable Technologies

In Parkinson’s disease (PD), abnormal movements consisting of hypokinetic and hyperkinetic manifestations commonly lead to nocturnal distress and sleep impairment, which significantly impact quality of life. In PD patients, these nocturnal disturbances can reflect disease-related complications (e.g., nocturnal akinesia), primary sleep disorders (e.g., rapid eye movement behaviour disorder), or both, thus requiring different therapeutic approaches. Wearable technologies based on actigraphy and innovative sensors have been proposed as feasible solutions to identify and monitor the various types of abnormal nocturnal movements in PD. This narrative review addresses the topic of abnormal nocturnal movements in PD and discusses how wearable technologies could help identify and assess these disturbances. We first examine the pathophysiology of abnormal nocturnal movements and the main clinical and instrumental tools for the evaluation of these disturbances in PD. We then report and discuss findings from previous studies assessing nocturnal movements in PD using actigraphy and innovative wearable sensors. Finally, we discuss clinical and technical prospects supporting the use of wearable technologies for the evaluation of nocturnal movements.

Using wearables to assess bradykinesia and rigidity in patients with Parkinson's disease: a focused, narrative review of the literature

The potential of using wearable technologies for the objective assessment of motor symptoms in Parkinson's disease (PD) has gained prominence recently. Nonetheless, compared to tremor and gait impairment, less emphasis has been placed on the quantification of bradykinesia and rigidity. This review aimed to consolidate the existing research on objective measurement of bradykinesia and rigidity in PD through the use of wearables, focusing on the continuous monitoring of these two symptoms in free-living environments. A search of PubMed was conducted through a combination of keyword and MeSH searches. We also searched the IEEE, Google Scholar, Embase, and Scopus databases to ensure thorough results and to minimize the chances of missing relevant studies. Papers published after the year 2000 with sample sizes greater than five were included. Studies were assessed for quality and information was extracted regarding the devices used and their location on the body, the setting and duration of the study, the "gold standard" used as a reference for validation, the metrics used, and the results of each paper. Thirty-one and eight studies met the search criteria and evaluated bradykinesia and rigidity, respectively. Several studies reported strong associations between wearable-based measures and the gold-standard references for bradykinesia, and, to a lesser extent, rigidity. Only a few, pilot studies investigated the measurement of bradykinesia and rigidity in the home and free-living settings. While the current results are promising for the future of wearables, additional work is needed on their validation and adaptation in ecological, free-living settings. Doing so has the potential to improve the assessment and treatment of motor fluctuations and symptoms of PD more generally through real-time objective monitoring of bradykinesia and rigidity.

Analysis of nocturnal hypokinesia and sleep quality in Parkinson's disease

Nocturnal hypokinesia/akinesia and sleep disorder are believed to be common in Parkinson's disease (PD), but are often underestimated. To date, only a few studies have focused on nocturnal symptoms related to motor function and sleep quality in PD patients, and the assessments were based mainly on the subjective descriptions of the patients. In this study, we assessed the relationships between motor symptoms and sleep quality in 29 PD patients (17 PD patients reporting impaired bed mobility (IBM) and 12 patients without IBM). All the participants were monitored using multisite inertial sensors and polysomnography in sleep-monitoring rooms for whole night. Compared with PD-IBM patients, PD+IBM patients tended to have fewer turning-over episodes and smaller degree turns. Meanwhile, PD+IBM patients had worse Pittsburgh Sleep Quality Index (PSQI) and Parkinson's Disease Sleep Scale (PDSS) scores, and less total sleep time (TST) than PD-IBM patients. Spearman correlation analyses found that the number of turning-over events showed negative correlations with disease duration (r = -0.378, P < 0.05) and Unified Parkinson's Disease Rating Scale (UPDRS) axial scores (r = -0.370, P < 0.05). Moreover, TST (r = 0.505, p < 0.05) and sleep efficiency (SE) (r = 0.473, p < 0.05) positively correlated with the number of turns in bed. Multivariate linear regression analyses showed that UPDRS axial scores and the number of turns were significantly associated with TST (both p < 0.05). In conclusion, the number of turns in bed and UPDRS axial scores were two significant factors affecting sleep quality. Multisite inertial sensors can be used to quantitatively evaluate nocturnal motor functions in PD patients.

Getting a good night sleep? The importance of recognizing and treating nocturnal hypokinesia in Parkinson's disease

When Parkinson's disease (PD) patients are asked about the quality of their sleep, their answers are dominated by difficulties associated with impaired mobility in bed, medically referred to as nocturnal hypokinesia. Nocturnal hypokinesia is symptomatic from the mid-stage of the disease, affecting up to 70% of PD patients, and contributes to poor sleep quality, and increased carer burden. Here we explore four areas of nocturnal hypokinesia that are relevant to clinical practice, namely: manifestations and definition; clinical assessment and objective monitoring; etiologies and contributing factors; and evidence-based therapeutic approaches. In addition, we provide an operational definition of what constitutes nocturnal hypokinesia and outline different methods of assessment, ranging from clinical interviews and rating scales to objective night-time monitoring with inertial sensors. Optimal management of nocturnal hypokinesia in PD begins with recognizing its manifestation by inquiring about cardinal symptoms and contributing factors from, not only patients, but also carers, followed by formal assessment, and the application of individualized evidence-based treatment. Night-time dopaminergic treatment is the primary therapy; however, careful clinical judgment is required to balance the benefits with the potential adverse events related to nocturnal dopaminergic stimulation. Future studies are needed to explore the practicality of home-based objective assessment of nocturnal hypokinesia, new therapeutic options not limited to dopaminergic medications, and non-pharmacologic approaches, including training on compensatory strategies and bedroom adaptations.

Impact of inability to turn in bed assessed by a wearable three-axis accelerometer on patients with Parkinson's disease

Background

Difficulty turning over in bed is a common night-time symptom in Parkinson’s disease (PD). We aimed to quantitatively evaluate overnight turnover movements using a three-axis accelerometer and to investigate whether inability to turn in bed is related to daytime sleepiness, sleep quality, and depressive mood in PD patients.

Methods

We examined 64 patients with PD (mean age, 73.3±8.21 years; modified Hoehn-Yahr [mH-Y] stage, 3.0±1.0; disease duration, 7.2±6.3 years; unified Parkinson's disease rating scale [UPDRS], 36.9±18.3). Overnight monitoring of turnover movements using a wearable three-axis accelerometer was performed in all patients. Nocturnal kinetic parameters including total time recumbent, total time supine, number of turnover movements, and mean interval between turnover movements were obtained. Daytime immobility was assessed using the Barthel index (B-I), UPDRS, and mH-Y stage. Patients were also assessed with the Epworth Sleepiness Scale (ESS), Parkinson’s Disease Sleep Scale-2 (PDSS-2), and Beck Depression Inventory (BDI).

Results

Number of turnover movements in bed correlated negatively with disease duration (r = -0.305; p<0.05), L-dopa-equivalent dose (r = -0.281; p<0.05), mH-Y staging (r = -0.336; p<0.01), total score of UPDRS (r = -0.386; p<0.01) and positively with B-I score (r = 0.365; p<0.01). Number of turnover movements in bed was generally inconsistent with awareness of turnover movement impairment as evaluated by PDSS-2 Item 9 scores, but patients who were never aware of impaired turnover movements showed ≥5 turnover movements overnight. Multivariate logistic regression analyses revealed no correlations between number of nocturnal turnover movements in bed and BDI, ESS, or PDSS-2. Use of anti-psychotic drugs was associated with ESS (p = 0.045). UPDRS was associated with PDSS-2 (p = 0.016).

Conclusion

Decreased number of turnover movements may not be a direct determinant of daytime sleepiness, sleep disorders, or depressive mood in PD patients. Use of anti-psychotic drugs and higher UPDRS score are factors significantly associated with daytime sleepiness and uncomfortable sleep, respectively.

Rotigotine for nocturnal hypokinesia in Parkinson's disease: Quantitative analysis of efficacy from a randomized, placebo-controlled trial using an axial inertial sensor

BACKGROUND

Nocturnal hypokinesia is a common symptom in Parkinson's disease (PD), negatively affecting quality of life of both patients and caregivers. However, evidence-based treatment strategies are limited.

OBJECTIVE

To evaluate the efficacy of rotigotine transdermal patch, using a wearable sensor, in the management of nocturnal immobility.

METHODS

34 PD subjects with nocturnal immobility were randomized to receive rotigotine transdermal patch (mean ± SD of 10.46 ± 4.63 mg/24 h, n = 17) or placebo patch (n = 17). Treatment was titrated to an optimal dose over 1-8 weeks, then maintained for 4 weeks. Primary endpoints were objective parameters assessing axial rotation measured using an axial inertial sensor (the NIGHT-Recorder) over two nights at the patients' home. Scale-based assessments were also performed.

RESULTS

There was a significant difference, in favor of rotigotine, in change from baseline score in the number of turns in bed (ANCOVA, p = 0.001), and degree of axial turn (p = 0.042). These objective improvements were mirrored by significantly greater improvements in clinical scale-based assessments, including the Unified Parkinson's Disease Rating Scale (UPDRS) total scores (p = 0.009), UPDRS-motor scores (p < 0.001), UPDRS-axial scores (p = 0.01), the Modified Parkinson's Disease Sleep Scale (p < 0.001), the Nocturnal Akinesia Dystonia and Cramp Scale (p = 0.003) and the eight-item PD Questionnaire (PDQ-8) scores (p = 0.01) from baseline to end of treatment in patients given rotigotine compared to placebo.

CONCLUSION

We show that the rotigotine patch provides a significant improvement in nocturnal symptoms as assessed using both objective measures and clinical rating scales. The study demonstrates the feasibility of using wearable sensors to record objective outcomes in PD-related clinical trials.

Impaired bed mobility: quantitative torque analysis with axial inertial sensors

Difficulty in turning in bed is rated as the most troublesome night-time symptom among Parkinson’s disease (PD) patients. Aim: To develop a practical objective method for home assessment of a patient’s ability to turn in bed. Methods: Nocturnal parameters and torque of self-turning in bed from 17 PD couples were assessed and compared using a wearable axial sensor for two nights in their homes. Results: The torque of axial rotation which indicates the ability of PD patients to turn in bed was significantly less than their spouses (p < 0.001). Significant correlations were observed between the torque of turning in bed and total unified Parkinson’s Disease Rating Scale score (r = 0.71; p = 0.001), and total Nocturnal Akinesia Dystonia and Cramp score (r = 0.634; p = 0.006). Conclusion: Our study confirms a decreased ability in turning in PD.

Clinical Assessments in Parkinson's Disease: Scales and Monitoring

Measurement of disease state is essential in both clinical practice and research in order to assess the severity and progression of a patient's disease status, effect of treatment, and alterations in other relevant factors. Parkinson's disease (PD) is a complex disorder expressed through many motor and nonmotor manifestations, which cause disabilities that can vary both gradually over time or come on suddenly. In addition, there is a wide interpatient variability making the appraisal of the many facets of this disease difficult. Two kinds of measure are used for the evaluation of PD. The first is subjective, inferential, based on rater-based interview and examination or patient self-assessment, and consist of rating scales and questionnaires. These evaluations provide estimations of conceptual, nonobservable factors (e.g., symptoms), usually scored on an ordinal scale. The second type of measure is objective, factual, based on technology-based devices capturing physical characteristics of the pathological phenomena (e.g., sensors to measure the frequency and amplitude of tremor). These instrumental evaluations furnish appraisals with real numbers on an interval scale for which a unit exists. In both categories of measures, a broad variety of tools exist. This chapter aims to present an up-to-date summary of the most relevant characteristics of the most widely used scales, questionnaires, and technological resources currently applied to the assessment of PD. The review concludes that, in our opinion: (1) no assessment methods can substitute the clinical judgment and (2) subjective and objective measures in PD complement each other, each method having strengths and weaknesses.

Quantitative demonstration of the efficacy of night-time apomorphine infusion to treat nocturnal hypokinesia in Parkinson's disease using wearable sensors

BACKGROUND

Nocturnal hypokinesia/akinesia is one of the common night-time symptoms in patients with Parkinson's disease (PD), negatively affecting quality of life of patients and caregivers. The recognition of this problem and treatment options are limited in clinical practice.

OBJECTIVES

To evaluate the efficacy of nocturnal apomorphine infusion, using a wearable sensor, in patients who are already on daytime continuous subcutaneous apomorphine infusion and still suffer from nocturnal hypokinesia.

METHODS

Nocturnal parameters in 10 PD patients before and during nocturnal infusion were assessed over two nights at their homes, using a wearable sensor (trunk). Nocturnal parameters included number, velocity, acceleration, degree, and duration of rolling over, and number of times they got out of bed. Correlations with validated clinical rating scales were performed.

RESULTS

Following nocturnal apomorphine infusion (34.8 ± 6.5 mg per night), there were significant improvements in the number of turns in bed (p = 0.027), turning velocity (p = 0.046), and the degree of turning (p = 0.028) in PD patients. Significant improvements of Modified Parkinson's Disease Sleep Scale (p = 0.005), the axial score of Unified Parkinson's Disease Rating Scale (p = 0.013), and Nocturnal Akinesia Dystonia and Cramp Scale (p = 0.014) were also observed.

CONCLUSION

Our study was able to demonstrate quantitatively the efficacy of nocturnal apomorphine infusion in PD patients with nocturnal hypokinesia and demonstrated the feasibility of using wearable sensors to yield objective and quantifiable outcomes in a clinical trial setting. More studies are needed to determine the long-term efficacy of this treatment in a large prospective cohort of PD patients.