Using Virtual Reality and Changes in Activities of Daily Living to Expose Prodromal Signs of Parkinson Disease

Jay Alberts, PhD

This is part 2 of a 2-part interview. Click here to view part 1.

Among the numerous technological advancements being incorporated in neurology care paradigms, virtual reality (VR) remains one of the more underutilized. This lag in integration has been in part because of VR-related sickness from these approaches, which result from sensory inconsistencies between the visual and vestibular systems. The newly designed Cleveland Clinic Virtual Reality Shopping (CC-VRS) platform uses an omnidirectional treadmill to mitigate the locomotion problem that typically occurs.

Led by Jay Alberts, PhD, a recently published study aimed to see whether this platform could quantify decline in the performance of instrumental activities of daily living (IADLs) as a prodromal marker of neurological disease, specifically Parkinson disease (PD). Here, patients completed both basic and complex virtual shopping experiences, such as walking 150 m and retrieving 5 items, and additional scenarios that increase the cognitive and motor demands of each task.

In interview with NeurologyLive®, Alberts, the Edward F. and Barbara A. Bell Endowed Chair at Cleveland Clinic, discussed the complexities that come with understanding early signs of PD, and how this VR platform works towards that. He provided insight on the difficulties with the current set of biomarkers and tools to assess the early stages of the disease, as well as whether technology like the CC-VRS can focus in on improving specific functions based on region of the brain.

NeurologyLive^®: How does this tool directly focus on elucidating the prodromal stages of PD?

Jay Alberts, PhD: As you know, I've done a lot of work with exercise and Parkinson disease. We've shown that exercise is great for PD, but this is a bit of a switch. We're still doing that work, but there's a bit of a switch in the sense that I think we need to be looking and trying to identify methods of earlier disease identification. That’s not new. This is a new approach in the sense that there are data out there that suggest that declines in instrumental activities of daily living predate the diagnosis of Alzheimer disease and Parkinson disease by 5 to 7 years. It predates clinical diagnosis. That's a big period of time that we're sort of potentially missing.

The challenge is, we don't do a good job right now of evaluating IADLs. There are some questionnaires in there that are okay, but not great. You could go to an occupational therapist, and be evaluated, but that isn't something that someone thinks of when they're 55. And it's difficult, it's 60 to 80 minutes. Insurance isn't going to pay for it. You need special space. Again, it's not overly objective or quantitative. If we can build a system and a platform that is an appropriate assessment of the major components of an IADL, then maybe we can track that those data over time and see, are these declining? And can this be a potential marker of appropriate marker for disease?

With that in mind, we are taking the system and placing it in the Sheffield Family Health Center, which is a family health center in Cleveland Clinic. Patients who are 55 and older just coming in for regular their annual visit will be asked if they want to participate in this project to track them over time to see, is there a potential prodromal marker here? I'm very excited about that, because the people at Sheffield are excited and enthusiastic about integrating this into to routine clinical care. That was our primary goal; to integrate into routine clinical care. We can get the data, but also making sure that it provides some usefulness or value. I want to be clear—we're not going to be able to say, “Oh, you now have Parkinson's or you're going to have Parkinson disease right now.” What we're looking to do is gather the data that will eventually allow us to raise a red or a yellow flag to tell someone to go to the neurologist because your ideals look a little off. Those are things that we really hope to do for sure.

How have we previously assessed prodromal stages of PD?

There have been some small genetic studies and tests that are ongoing. Again, they have probably explained about 1% or so of the cases of PD. There are probably a few stronger biomarkers, genetic biomarkers in Alzheimer disease. But in general, it's been a bit of a mixed bag in terms of looking for blood biomarkers or other imaging biomarkers. The challenge with many of these is they're expensive and their integration into routine clinical care is hard to imagine at the moment, just because of the cost. As we all know, as healthcare continues to constrain and attempt to constrain costs, these types of tests are hard to imagine. We'll see. Again, I don't think this is going to be the panacea. I think we have to be obviously looking at other biomarkers as well, and maybe a combination of something that is even stronger, and can identify it earlier, faster, and cheaper. That's where we're really looking at; how do we scale something, so it provides value to the person right now? Because even when you're 55—I'm not there yet, close, but you lose your keys, you forget where you parked, and you’re saying, “Am I all right?” Maybe there's something to provide some level of assurance to folks as well that they are.

Can we use technology like this to specifically target key functions based on brain region?

We are with this new Michael J. Fox Foundation study. If you think about the subthalamic nucleus, its divided into 3 areas: cognitive, limbic, and sensory-motor. We've developed 3 different additional paradigms or virtual home environments that patients in the study will go and perform. One of them is anxiety, it's an anxiety-provoking paradigm. They are walking in the kitchen, and they have to go through these double doors. Suddenly, the double doors open right in front of them, and they basically have to walk on a plank to a little platform, make a turn and come back. You think, oh, maybe that's not anxiety, but it really does promote anxiety because people are immersed. You feel it. You can see people looking down at that plank, they’re walking and their gait changes or their heart rate increases. That's where we'll be looking at the neural activity within the limbic region of the STN (subthalamic nucleus) to see, does it change? How is it changing? How is it responding to this? Similarly, we have a cognitive module where patients do a dual task while walking through that kitchen. Again, looking at the cognitive area, the STN. I think we can [target key functions] as long as you develop the paradigm to potentially map onto to the area that you're interested in.

Transcript edited for clarity.