Using virtual reality and changes in activities of daily living to expose prodromal signs of Parkinson’s disease
This is part 2 of a 2 part interview. Click here to see part 1.
Of the many technological advancements incorporated into neurological care paradigms, virtual reality (VR) remains one of the most underutilized. This delay in integration is partly due to the virtual reality-related illnesses of these approaches, which result from sensory inconsistencies between the visual and vestibular systems. Cleveland Clinic’s newly designed Virtual Reality Shopping (CC-VRS) platform uses an omni-directional treadmill to alleviate the locomotion problem that commonly occurs.
Led by Jay Alberts, PhD, a recently published study investigated whether this platform could quantify decreased performance in instrumental activities of daily living (IADL) as a prodromal marker of neurological diseases, specifically Parkinson’s disease (PD). ). Here, patients performed basic and complex virtual shopping experiences, such as walking 150 m and retrieving 5 items, as well as additional scenarios that increase the cognitive and motor demands of each task.
In interview with NeurologyLive®, Alberts, Edward F. and Barbara A. Bell Endowed Chair at the Cleveland Clinic, discussed the complexities that come with understanding the early signs of Parkinson’s disease and how this virtual reality platform works in that Sens. He provided insight into the difficulties with the current set of biomarkers and tools to assess the early stages of the disease, as well as whether a technology like CC-RSV can focus on improving specific functions based on the brain region.
NeurologyLive®: How does this tool focus directly on elucidating the prodromal stages of PD?
Jay Alberts, PhD: As you know, I have worked extensively on exercise and Parkinson’s disease. We’ve shown that exercise is great for PD, but that’s a bit of a change. We continue to do this work, but there is a bit of a change in the sense that I think we have to look and try to identify methods of early identification of diseases. It’s not new. This is a novel approach in that there is evidence to suggest that the decline in instrumental activities of daily living predates the diagnosis of Alzheimer’s disease and Parkinson’s disease by 5 to 7 year. It predates the clinical diagnosis. This is a large period of time that we are potentially missing.
The challenge is that we’re not doing a good job right now of evaluating IADLs. There are quizzes in there that are okay, but not great. You could go to an occupational therapist and get assessed, but that’s not something you think of at 55. And it’s hard, it’s 60 to 80 minutes. Insurance will not pay. You need a special space. Again, it’s not too objective or quantitative. If we can build a system and platform that is a proper assessment of the major components of an IADL, then maybe we can track that data over time and see if it’s going down? And can this be a potential marker of a suitable marker for the disease?
With that in mind, we’re taking the system and putting it in Sheffield Family Health Center, which is a Cleveland Clinic family health center. Patients 55 and older who come just for their regular annual visit will be asked if they would like to participate in this project to follow them over time to see if there is a potential prodromal marker here? I am very excited about this, as the people of Sheffield are thrilled and enthusiastic about integrating this into routine clinical care. This was our main objective; to be incorporated into routine clinical care. We can get the data, but also make sure it provides utility or value. I want to be clear – we’re not going to be able to say, “Oh, you have Parkinson’s now or you’re going to have Parkinson’s right now.” What we’re looking to do is put together the data that will eventually allow us to raise a red or yellow flag to tell someone to go to the neurologist because your ideals seem a little off. These are things that we really hope to do for sure.
How have we previously assessed the prodromal stages of PD?
There have been some small studies and genetic testing that are going on. Again, they probably explained about 1% of PD cases. There are probably a few more powerful biomarkers, genetic biomarkers in Alzheimer’s disease. But in general, the search for blood biomarkers or other imaging biomarkers has been a bit mixed. The challenge with many of them is that they are expensive and integrating them into routine clinical care is hard to imagine at the moment, simply because of the cost. As we all know, as healthcare continues to limit and attempt to contain costs, these types of tests are hard to imagine. We will see. Again, I don’t think this will be a panacea. I think we obviously need to look at other biomarkers as well, and maybe a combination of something that’s even stronger, and can identify it earlier, faster, and at a lower cost. This is where we really look; how can we scale something, so that it brings value to the person right now? Because even when you’re 55, I’m not there yet, I’m close, but you lose your keys, you forget where you parked and you say, “Are you okay? Maybe there is something to provide some level of assurance to people that they are.
Can we use technology like this to specifically target key brain region-based functions?
We are with this new study from the Michael J. Fox Foundation. If you think of the subthalamic nucleus, it is divided into 3 areas: cognitive, limbic, and sensory-motor. We have developed 3 different additional paradigms or virtual home environments that the study patients will go to perform. One of them is anxiety, it’s an anxiety-provoking paradigm. They walk into the kitchen, and they have to go through those double doors. Suddenly, the double doors open right in front of them, and they basically have to walk on a plank to a small platform, take a turn, and come back. You think, oh, maybe it’s not anxiety, but it really promotes anxiety because people are immersed in it. You feel it. You can see people looking at this board, they are walking and their gait changes or their heart rate increases. This is where we’re going to look at neural activity in the limbic region of the STN (subthalamic nucleus) to see, is it changing? How does it change? How does he react to this? Similarly, we have a cognitive module where patients perform a dual task while walking through this kitchen. Again, looking at the cognitive domain, the STN. I think we can [target key functions] as long as you expand the paradigm to potentially map the area of interest.
Transcript edited for clarity.