Incorporating Augmented Reality to Treat Parkinson Disease Gait Problems

Jay Alberts, PhD

Postural instability, or difficulty balancing, is one of the most challenging of the major Parkinson disease (PD) movement symptoms. Instability often leads to falls, the most common reason for emergency room visits and the largest motor related contributor to health care costs in patients with PD. Research has shown that early identification of instability, persistent monitoring, and effective timely intervention is necessary to curb the growing economical and emotional burden of postural instability in patients with PD.

Recently, a group of investigators published data in the journal of Neurorehabilitation and Neural Repair from a randomized controlled trial assessing the DART platform, a dual-task augmented reality treatment for postural instability and gait dysfunction (PIGD). The single-blind study assessed the effects of DART in patients with PD compared with a traditional dual-task training program. Comprised of 47 patients, both groups completed 16 therapeutic sessions over 8 weeks, with primary outcomes that included clinical ratings and single- and dual-task biomechanical outcomes.

Following the publication, NeurologyLive® reached out to lead investigator Jay Alberts, PhD, to get his thoughts on the trial and its significance. Alberts, the Edward F. and Barbara A. Bell Endowed Chair at Cleveland Clinic, provided commentary on the DART platform and its build, what went into trial inclusion, and the potential for augment reality to assist in the treatment of patients with neurologic disorders.

Can you provide insight on what the DART platform is and how it differs from traditional dual-task training programs?

The DART platform embodies the principles of traditional dual-task training, however DART delivers DTT via augmented reality. Augmented reality, unlike Virtual reality, is the placement of digital objects in the real world environment of the patient (if you have a car in which the speed can be displayed digitally on the windshield, that is augmented reality… or the amazon app that lets you see in your phone how a chair will look in your living room). The DART platform delivers a series of cognitive and motor tasks to the patient and the hololens2 device can monitor and automatically score cognitive and motor performance for a provider to review and to increase or decrease the difficulty of the next session. Hence, it facilitates a more objective patient specific approach to treating a patient (e.g. more emphasis on motor or more emphasis on cognitive).

How do you decide what types of patients are optimal for this type of trial? Discuss a little that went into patient selection, trial inclusion

The goal of this trial was to evaluate DART as a digital therapeutic for the delivery of an intervention that can improve PD gait and postural stability. In order for a technology to be considered a digital therapeutic it must be compared to a reference therapy that has already been validated and demonstrated efficacy via randomized clinical trials. This requires a study design in which one uses a non-inferiority design (e.g. the new technology should be as good as the reference treatment). For this trial, we enrolled PD patients that reported postural instability and gait dysfunction and had a history of falling. This population was expected to benefit from the dual-task training.

What were the greatest take-home points the clinical community, and neurologists specifically, should gain from this study?

We now have a properly validate digital therapeutic for the treatment of PD gait and postural dysfunction. This is important as treating gait dysfunction is difficult over time and gait continues to decline as the disease progresses. Having a digital therapeutic to use in the treatment of PIGD will empower therapists and patients to utilize dual-task training.

What is the feasibility look like for incorporating more dual-task types of programs across PD clinics in the US?

This is an early study for sure, however, I think the future is bright for this technology to enable the use of dual-task training as it addresses many of the barriers (e.g. selection of tasks, providing feedback to the patient, adjusting and titrating difficulty of the practice sessions). Notably, we do not think this will take the place of physical therapy, but can be used as a digital tool in their therapy tool kit.

How can we build on this data? What types of follow up research can we conduct

The next step is to evaluate the effectiveness of this technology in the home environment of the patient. We believe the DART can be used in the home and if effective it could empower and bring a validated therapy to the majority of PD patients who do not live within a reasonable distance to a major rehabilitation or academic medical center.